What is the recommended treatment with Solucortef (hydrocortisone) for a patient with adrenal insufficiency?

Treatment of Adrenal Insufficiency with Solu-Cortef (Hydrocortisone)

Maintenance Therapy

For chronic adrenal insufficiency, hydrocortisone 15-25 mg daily divided into 2-3 doses is the standard replacement therapy, with the first dose taken immediately upon waking and the last dose at least 6 hours before bedtime. 1

• The typical dosing schedule is 10 mg upon waking, 5 mg at midday, and 2.5-5 mg in the early afternoon 1
• In children, the dose is 6-10 mg/m² body surface area daily 1
• Patients with primary adrenal insufficiency additionally require fludrocortisone 50-200 µg once daily for mineralocorticoid replacement 1

Acute Adrenal Crisis Management

Adrenal crisis requires immediate treatment with hydrocortisone 100 mg IV bolus, followed by 100 mg every 6-8 hours (or 200 mg/24h continuous infusion) until recovery, along with rapid IV isotonic saline at 1 L/hour initially. 1

• Treatment should never be delayed for diagnostic procedures 1
• Continuous IV infusion of 200 mg/24h is superior to bolus dosing for maintaining physiological cortisol concentrations during major stress 2
• An initial bolus of 50-100 mg hydrocortisone should precede the continuous infusion 2
• Administer 3-4 L of 0.9% saline over 24 hours with frequent hemodynamic monitoring 3
• Taper to double the oral maintenance dose for 24-48 hours once the patient can eat and drink, then return to normal maintenance 1

Perioperative Management

For major surgery, give hydrocortisone 100 mg IV/IM just before anesthesia, followed by continuous infusion of 200 mg/24h until the patient can take oral medications. 1

Major Surgery Protocol:

• Administer 100 mg hydrocortisone IV/IM immediately before anesthesia 1
• Continue 100 mg every 6 hours (or 200 mg/24h continuous infusion) until able to eat and drink 1
• Once oral intake resumes, double the usual oral dose for 48+ hours 1
• Taper to normal maintenance dose within 48 hours for uncomplicated recovery, or up to one week for major/complicated surgery 1

Minor Surgery Protocol:

• Give 100 mg hydrocortisone IV/IM just before the procedure 1
• Double oral dose for 24 hours postoperatively, then return to normal maintenance 1

Dental Procedures:

• For major dental surgery: 100 mg hydrocortisone IM before anesthesia, then double oral dose for 24 hours 1
• For minor dental procedures: extra morning dose 1 hour prior, then double oral dose for 24 hours 1

Obstetric Management

During labor and delivery, give hydrocortisone 100 mg IM at onset of labor, repeated every 6 hours if necessary, or as continuous IV infusion of 200 mg/24h. 1

• Women may require higher maintenance doses during the third trimester (after 20 weeks) 1
• After delivery, double the oral dose for 24-48 hours, then taper to normal maintenance 1
• Monitor blood pressure and serum electrolytes rather than plasma renin activity for fludrocortisone dose adjustment during pregnancy 1

Critical Pitfalls to Avoid

Dexamethasone is inadequate for primary adrenal insufficiency as it lacks mineralocorticoid activity and should never be used as sole therapy. 1

• Even mild gastrointestinal upset can precipitate adrenal crisis, as patients cannot absorb oral medications when they need them most 1
• The frequency of acute adrenal crises is 6-8 per 100 patient-years, with common precipitants being vomiting/diarrhea, infections, surgery, and injuries 1
• Medication errors and omissions during hospital stays account for 8.6% of adrenal crises 1
• Stopping corticosteroids abruptly after long-term therapy can precipitate crisis; always taper gradually 4

Patient Education and Safety Measures

All patients must wear medical alert identification jewelry, carry a steroid emergency card, and have supplies for self-injection of parenteral hydrocortisone. 1

• Patients require education on doubling or tripling oral doses during minor illnesses with fever 1
• For vomiting or inability to take oral medications, immediate parenteral hydrocortisone 100 mg IM and emergency medical attention are required 1
• Regular physical activity does not require dose adjustment, but intense or prolonged exercise may need an extra 5 mg hydrocortisone beforehand 1

Monitoring and Follow-up

Annual assessment should include evaluation of symptoms, weight, blood pressure, and serum electrolytes (sodium, potassium). 1

• Screen for associated autoimmune conditions, particularly thyroid dysfunction 1
• Monitor bone mineral density every 3-5 years to assess for complications of glucocorticoid therapy 1
• Clinical assessment is the primary monitoring tool, as biochemical markers are unreliable for optimal replacement 5
• Signs of over-replacement include weight gain, insomnia, and peripheral edema 5
• Signs of under-replacement include fatigue, weakness, nausea, vomiting, and hyperpigmentation 5

Why Continuous Infusion is Superior

Research demonstrates that continuous IV infusion is the only administration mode that persistently achieves median cortisol concentrations in the range observed during major stress, making it superior to intermittent bolus dosing. 2

• Intermittent bolus administration (whether IV, IM, or oral every 6 hours) results in supraphysiological peaks and subtherapeutic troughs 2
• Linear pharmacokinetic modeling confirms that 200 mg/24h continuous infusion, preceded by a 50-100 mg bolus, best maintains cortisol in the required range during major stress 2
• This approach reduces the risk of both under-treatment (leading to crisis) and over-treatment (causing hypernatremia and Cushing-like effects) 4, 2