Is a patient taking 22.5mg of hydrocortisone (cortisol replacement) for adrenal insufficiency considered immunosuppressed?

Immunosuppression Status with Physiologic Hydrocortisone Replacement

A patient taking 22.5 mg of hydrocortisone daily as physiologic replacement for adrenal insufficiency is NOT considered immunosuppressed. This dose falls within the standard replacement range and mimics normal cortisol production rather than providing pharmacologic immunosuppression.

Physiologic vs. Immunosuppressive Dosing

The key distinction is that replacement therapy restores normal cortisol levels rather than exceeding them:

• Normal adrenal function produces 5-10 mg of cortisol per m² of body surface area daily, translating to 15-25 mg of hydrocortisone for replacement 1
• The patient's dose of 22.5 mg falls squarely within this physiologic replacement range 1, 2
• Hydrocortisone is used as replacement therapy in adrenocortical deficiency states to restore normal function, not to provide immunosuppression 3

Evidence from Vaccination Guidelines

The 2022 American College of Rheumatology vaccination guidelines provide clear thresholds for immunosuppression:

• Glucocorticoids are considered "low-level immunosuppression" only when doses are equivalent to prednisone ≥20 mg/day or ≥2 mg/kg/day for patients weighing <10 kg 4
• Converting the patient's dose: 22.5 mg hydrocortisone = approximately 5.6 mg prednisone equivalent (using the 4:1 conversion ratio) 5
• This is well below the 20 mg/day prednisone threshold for immunosuppression 4

Clinical Implications

For practical clinical decision-making:

• Live attenuated vaccines can be administered without holding hydrocortisone when the dose is <20 mg prednisone equivalent 4
• The patient does not require special precautions for immunosuppression in surgical or infectious disease contexts
• Modified-release hydrocortisone formulations at physiologic doses have been shown to be less immunosuppressive than conventional multiple daily dosing regimens 6

Important Caveats

Situations where immunosuppression concerns may arise:

• During stress dosing (doubling or tripling the maintenance dose during illness), temporary mild immunosuppression may occur, but this is short-term 1
• If the patient were taking >20 mg prednisone equivalent chronically (>80 mg hydrocortisone daily), immunosuppression would be a concern 4
• The distinction between replacement and pharmacologic dosing is critical—replacement restores deficiency while pharmacologic doses suppress immune function 4, 3