What is the appropriate corticosteroid (e.g. hydrocortisone, prednisone) dose for a patient with suspected adrenal insufficiency?

Corticosteroid Dosing for Suspected Adrenal Insufficiency

Immediate Management Based on Clinical Severity

For patients with suspected adrenal insufficiency, the corticosteroid dose depends entirely on clinical severity: stable outpatients require physiologic replacement (hydrocortisone 15-25 mg daily or prednisone 3-5 mg daily), moderately symptomatic patients need 2-3 times maintenance dosing (hydrocortisone 30-50 mg daily or prednisone 20 mg daily), and critically ill patients with suspected adrenal crisis require immediate IV hydrocortisone 100 mg bolus followed by 50-100 mg every 6-8 hours. 1, 2

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Dosing Algorithm by Clinical Presentation

Grade 1: Mild or Asymptomatic (Confirmed Diagnosis, Stable)

• Maintenance glucocorticoid replacement: Hydrocortisone 15-25 mg daily in divided doses (typically 2/3 morning, 1/3 early afternoon) OR prednisone 3-5 mg daily 1, 2
• For primary adrenal insufficiency: Add fludrocortisone 0.05-0.1 mg daily for mineralocorticoid replacement 1, 2
• Hydrocortisone is preferred over long-acting steroids because it allows recreation of the diurnal cortisol rhythm 1

Grade 2: Moderate Symptoms (Able to Perform Activities of Daily Living)

• Outpatient stress dosing: Hydrocortisone 30-50 mg total daily dose OR prednisone 20 mg daily 1
• This represents 2-3 times the maintenance dose 1
• Decrease to maintenance doses after 2 days once symptoms resolve 1
• For primary adrenal insufficiency: Initiate fludrocortisone 0.05-0.1 mg daily if not already prescribed 1

Grade 3-4: Severe Symptoms or Adrenal Crisis (Life-Threatening, Unable to Perform Activities)

• Immediate IV treatment: Hydrocortisone 50-100 mg IV bolus, then 50-100 mg IV/IM every 6-8 hours 1, 3, 2
• Aggressive fluid resuscitation: 0.9% normal saline at 1 L/hour initially (at least 2L total) 1
• Never delay treatment for diagnostic testing if adrenal crisis is suspected 4, 2
• Tapering protocol: Once hemodynamically stable and off vasopressors, taper IV stress-dose steroids down to oral maintenance doses over 5-7 days 3

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Critical Dosing Considerations

Peri-operative or High-Stress Situations

• Minor stress (e.g., dental procedures, minor illness): Double the usual daily dose for 1-2 days 1
• Moderate stress (e.g., moderate surgery, fever >38°C): Hydrocortisone 50-75 mg daily in divided doses 1
• Major stress (e.g., major surgery, severe illness): Hydrocortisone 100-150 mg daily in divided doses, or continuous IV infusion 1
• Dexamethasone 8 mg is equivalent to approximately 200 mg hydrocortisone but lacks mineralocorticoid activity and is inadequate for primary adrenal insufficiency 1

Special Diagnostic Scenario

• If you need to treat suspected adrenal crisis but still want to perform diagnostic testing later: Use dexamethasone 4 mg IV instead of hydrocortisone, as dexamethasone does not interfere with cortisol assays 4
• Draw blood for cortisol and ACTH before any glucocorticoid administration if possible, but never delay treatment 4, 2

Dose Equivalencies (Critical for Conversion)

• 10 mg hydrocortisone = 2 mg prednisolone = 0.1 mg dexamethasone 1
• Hydrocortisone 20 mg = prednisone 5 mg 5

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Common Pitfalls to Avoid

Dosing Errors

• Do not use dexamethasone alone for primary adrenal insufficiency because it has no mineralocorticoid activity 1
• Do not rely on fixed-duration protocols rigidly—taper stress dosing based on clinical status (vasopressor requirements, hemodynamic stability) rather than arbitrary timeframes 3
• Do not taper abruptly from stress doses, as this can cause hemodynamic and immunologic rebound 3

Diagnostic Delays

• Never wait for diagnostic test results to treat suspected adrenal crisis—mortality is high if untreated 4
• Treatment of suspected acute adrenal insufficiency should NEVER be delayed by diagnostic procedures 4, 2

Medication Interactions

• When treating concurrent hypothyroidism and adrenal insufficiency: Start corticosteroids several days before initiating thyroid hormone replacement to prevent precipitating adrenal crisis, as thyroid hormone accelerates cortisol clearance 1, 4
• Exogenous steroids (prednisolone, dexamethasone, inhaled fluticasone) can suppress the HPA axis and confound diagnostic testing 1, 4

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Patient Education Requirements (Mandatory for All Patients)

• Stress dosing education: All patients need instruction on doubling or tripling their dose during illness, fever, or physical stress 1, 2
• Emergency injectable kit: Prescribe hydrocortisone 100 mg IM injection kit with self-injection training 1, 2, 6
• Medical alert identification: Patients must wear a medical alert bracelet or necklace indicating adrenal insufficiency to trigger stress-dose corticosteroids by emergency medical personnel 1, 2
• When to seek emergency care: Educate on warning signs of impending adrenal crisis (persistent vomiting, severe diarrhea, unexplained hypotension, altered mental status) 1

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Monitoring and Follow-Up

Signs of Under-Replacement

• Morning nausea and lack of appetite are particularly common in under-replaced patients 4
• Lethargy, poor appetite, weight loss, and increased skin pigmentation suggest inadequate dosing 4
• Practical tip: Taking the first hydrocortisone dose earlier in the morning (then returning to sleep) may relieve morning nausea 4

Signs of Over-Replacement

• Weight gain, hypertension, hyperglycemia, osteoporosis, and cushingoid features suggest excessive dosing 7
• Recent evidence suggests lower maintenance doses (15 mg hydrocortisone daily) may be more physiologic than the traditional 20-25 mg daily to avoid long-term adverse outcomes 7

Endocrine Consultation

• Mandatory for: All newly diagnosed patients, pre-operative planning, recovery protocols after prolonged steroid use, and any patient with recurrent adrenal crises 1, 4