What is the typical dosage of hydrocortisone (cortisol) for a patient?

Hydrocortisone Dosage for Adrenal Insufficiency

For chronic maintenance therapy in adrenal insufficiency, hydrocortisone should be dosed at 15-20 mg daily in divided doses, typically given as 10 mg upon awakening and 5 mg in early afternoon, with adjustments based on body weight and clinical response. 1, 2

Standard Maintenance Dosing Regimens

Primary dosing approach:

• Total daily dose: 15-20 mg hydrocortisone divided into 2-3 doses 1
• Morning dose (upon awakening, before 9 AM): 10 mg 2
• Early afternoon dose (around 2 PM): 5 mg 2
• Optional third dose (if needed): 2.5-5 mg at 4 PM 2

Alternative equivalent regimens:

• Prednisolone 4-5 mg daily (equivalent to 20-25 mg hydrocortisone) 3, 2
• Prednisone 4-5 mg daily as single morning dose 3
• Note: 20 mg hydrocortisone = 5 mg prednisone/prednisolone 1, 4

Weight-Based Dosing Optimization

Body weight is the most important predictor of hydrocortisone clearance, and weight-adjusted dosing reduces interpatient variability in drug exposure from 50% to 22%. 5

• Weight-adjusted dosing decreases maximum cortisol concentration variability from 31% to 7% 5
• Fixed dosing overexposes patients to cortisol by 6.3%, while weight-adjusted dosing reduces overexposure to <5% 5
• Thrice-daily dosing before food is recommended for optimal absorption 5

Severity-Based Dosing Algorithm

Grade 1 (Asymptomatic/Mild):

• Hydrocortisone 15-20 mg in divided doses 1
• Consider holding immune checkpoint inhibitors until stabilized on replacement 1
• Titrate up to maximum 30 mg daily for residual symptoms 1
• Reduce dose if signs of iatrogenic Cushing's develop (bruising, thin skin, edema, weight gain) 1

Grade 2 (Moderate symptoms, able to perform ADL):

• Stress dosing at 2-3 times maintenance: 30-50 mg total daily dose 1
• Alternative: Prednisone 20 mg daily 1
• Taper back to maintenance after 2 days 1

Grade 3-4 (Severe/Life-threatening):

• Immediate IV hydrocortisone 50-100 mg every 6-8 hours 1
• Normal saline resuscitation (at least 2L) 1
• Hospitalization required 1
• Taper stress-dose corticosteroids down to oral maintenance over 5-7 days 1

Peri-operative and Stress Dosing

Major surgery:

• Hydrocortisone 100 mg IV at induction 1
• Followed immediately by continuous infusion 200 mg/24 hours 1
• Alternative: Hydrocortisone 50 mg IM every 6 hours 1
• Resume enteral glucocorticoid at double pre-surgical dose for 48 hours if recovery uncomplicated 1

Labor and vaginal delivery:

• Hydrocortisone 100 mg IV at onset of labor 1
• Followed by continuous infusion 200 mg/24 hours 1
• Alternative: 100 mg IM followed by 50 mg every 6 hours IM 1

Pediatric major surgery:

• Hydrocortisone 2 mg/kg at induction 1
• Continuous IV infusion based on weight: up to 10 kg = 25 mg/24h; 11-20 kg = 50 mg/24h; >20 kg prepubertal = 100 mg/24h; pubertal = 150 mg/24h 1

Septic Shock Dosing

For septic shock when adequate fluid resuscitation and vasopressors fail to restore hemodynamic stability, use IV hydrocortisone 200 mg per day. 1

• Do NOT use hydrocortisone if hemodynamic stability can be achieved with fluids and vasopressors alone 1
• Administer as continuous infusion rather than bolus dosing 1
• Taper when vasopressors no longer required 1
• Do NOT use corticosteroids for sepsis without shock 1

Mineralocorticoid Replacement

Primary adrenal insufficiency requires fludrocortisone 0.05-0.1 mg daily, titrated based on volume status, sodium level, and renin (target upper half of reference range). 1

• Secondary adrenal insufficiency does NOT require fludrocortisone, as aldosterone production remains intact 2
• Maximum fludrocortisone dose: 0.2 mg daily 6

Critical Timing Considerations

All hydrocortisone doses should be taken before food, with the largest portion (typically 2/3) given upon awakening before 9 AM. 3, 5

• Food delays hydrocortisone absorption 5
• Last dose should be no later than 4-6 hours before bedtime to avoid insomnia 3
• For patients with morning nausea, wake earlier to take first dose then return to sleep 3

Monitoring and Dose Adjustment

Clinical assessment is the primary method for monitoring adequacy—NOT laboratory cortisol levels. 1

• Single serum cortisol measured 4 hours after hydrocortisone predicts cortisol AUC (r² = 0.78) 5
• Signs of over-replacement: weight gain, insomnia, peripheral edema, bruising, thin skin, hypertension, hyperglycemia 1, 3
• Signs of under-replacement: lethargy, nausea, poor appetite, weight loss, increased pigmentation 3

Drug Interactions Requiring Dose Adjustment

Medications that INCREASE hydrocortisone requirements:

• Anti-epileptics and barbiturates 3, 2
• Rifampin and other antituberculosis medications 3, 2
• Topiramate and etomidate 2

Substances that DECREASE requirements (should be avoided):

• Grapefruit juice 3, 2
• Licorice 3, 2

Essential Patient Education

All patients must be educated on stress dosing: double or triple the dose during febrile illness, infection, or minor stress. 2

• Provide emergency injectable hydrocortisone for severe illness/vomiting 1
• Medical alert bracelet or necklace is mandatory 1
• Educate on when to seek emergency care for impending adrenal crisis 1
• For major stress (surgery, severe infection): IV hydrocortisone 100 mg required 2

Common Pitfalls to Avoid

• Never start thyroid hormone replacement before initiating hydrocortisone in patients with multiple hormone deficiencies—this can precipitate adrenal crisis. 1
• Do NOT use ACTH stimulation test to guide hydrocortisone dosing in septic shock 1
• Do NOT abruptly discontinue hydrocortisone after long-term therapy—taper gradually 4
• Do NOT use long-acting synthetic glucocorticoids (prednisone, dexamethasone) as first-line for chronic replacement due to undesirable metabolic effects 6
• Morning cortisol measurements are NOT diagnostic in patients already on corticosteroids 1