What is the dosage and usage of Hydrocortisone (cortisone)

Hydrocortisone Dosing and Usage

Standard Maintenance Dosing for Adrenal Insufficiency

For chronic adrenal insufficiency, hydrocortisone should be dosed at 15-25 mg daily in divided doses, typically given as 10 mg upon awakening, 5 mg at midday, and 2.5-5 mg in the early afternoon (no later than 4 PM). 1

Specific Dosing Regimens

• Total daily dose: 15-25 mg hydrocortisone (or 25-37.5 mg cortisone acetate) 1
• Three-dose regimen (preferred): 10 mg at 0700h + 5 mg at 1200h + 2.5-5 mg at 1600h 1
• Two-dose regimen (alternative): 15 mg at 0700h + 5 mg at 1200h, or 10 mg + 10 mg 1
• Steroid equivalency: 20 mg hydrocortisone = 5 mg prednisone = 0.75 mg dexamethasone 2, 3

Timing Considerations

• The largest dose must be given upon awakening (before 9 AM) to mimic physiological cortisol rhythm 4
• The final dose should be taken no later than 4-6 hours before bedtime to avoid insomnia 4
• Patients experiencing morning nausea may wake earlier to take the first dose, then return to sleep 1

Stress Dosing for Surgery and Major Illness

For major surgery or severe stress, give hydrocortisone 100 mg IV bolus at induction, followed immediately by continuous IV infusion of 200 mg over 24 hours. 1, 2

Perioperative Protocol

• Intraoperative: 100 mg IV bolus at induction + 200 mg/24h continuous infusion 1
• Alternative if infusion unavailable: 50 mg IV/IM every 6 hours 1, 2
• Postoperative: Continue 200 mg/24h IV infusion while NPO or vomiting 1
• Transition to oral: Double the usual maintenance dose for 48 hours after minor surgery, or up to 1 week after major surgery 1, 2

Stress Dosing for Illness

• Mild illness (fever, minor infection): Double the regular oral maintenance dose 2
• Moderate illness: 2-3 times the maintenance dose 4
• Severe illness/adrenal crisis: 50-100 mg IV every 6-8 hours, taper over 5-7 days 5, 2

Emergency Management

For suspected adrenal crisis with unexplained hypotension unresponsive to fluids, give hydrocortisone 100 mg IV immediately, followed by 50 mg IV every 6 hours. 1, 2

Critical Actions

• Never delay treatment while awaiting diagnostic confirmation 2
• Adrenal crisis can occur even when plasma cortisol levels appear normal (relative adrenal insufficiency) 5, 2
• All patients must carry emergency hydrocortisone injection kit (100 mg) for self-administration 2

Obstetric Dosing

At onset of active labor (contractions every 5 minutes for 1 hour, or cervical dilation >4 cm), give hydrocortisone 100 mg IV bolus, followed by 200 mg/24h continuous infusion. 1, 2

• Alternative: 100 mg IM followed by 50 mg IM every 6 hours 1, 2
• Cesarean section: Follow major surgery protocol 1

Pediatric Dosing

• Initial dose range: 0.56-8 mg/kg/day in 3-4 divided doses (20-240 mg/m²/day) 6
• Surgery: 2 mg/kg IV at induction 2
• Major surgery postoperative: 2 mg/kg IV/IM every 4 hours or continuous infusion 2

Mineralocorticoid Replacement

Patients with primary adrenal insufficiency require fludrocortisone 0.05-0.2 mg once daily upon awakening, in addition to hydrocortisone. 1, 5

• Higher doses (up to 500 mcg daily) may be needed in children, young adults, or third trimester pregnancy 1
• Monitor for salt craving, orthostatic hypotension, and peripheral edema 1
• Avoid diuretics, NSAIDs, and drospirenone-containing contraceptives as they interact with fludrocortisone 1

Drug Interactions Requiring Dose Adjustment

Medications that increase hydrocortisone requirements:

• Anti-epileptics/barbiturates 1
• Antituberculosis drugs 1
• Topiramate 1

Medications that decrease hydrocortisone requirements:

• Grapefruit juice 1
• Licorice 1

Administration Routes and Preparation

IV administration (FDA-approved): 6

• Bolus: Administer over 30 seconds (100 mg) to 10 minutes (500+ mg)
• Infusion: Dilute in 100-1000 mL of 5% dextrose or normal saline
• Reconstitute 100 mg vial with ≤2 mL bacteriostatic water

Oral administration: 3

• Initial dosage range: 20-240 mg/day depending on disease severity
• Maintenance: Decrease in small increments to lowest effective dose

Critical Pitfalls to Avoid

• Never start thyroid hormone, testosterone, or estrogen before corticosteroids, as these accelerate cortisol clearance and can precipitate adrenal crisis 5, 2
• Medication errors and omissions during hospitalization cause 8.6% of adrenal crises 1
• High-dose therapy should not continue beyond 48-72 hours due to hypernatremia risk 6
• Patients on chronic steroids have 2-3 times higher mortality risk if inadequately covered during stress 1

Patient Education Requirements

• All patients need medical alert bracelet/necklace and steroid emergency card 2, 4
• Education on stress dosing for sick days is mandatory 5, 4
• Patients must understand when to self-administer emergency injection 2
• Avoid potassium-containing salts; allow unrestricted sodium intake 1