What is the recommended dose of hydrocortisone for adults and children with various conditions, including adrenal insufficiency, asthma, and severe allergic reactions?

Hydrocortisone Dosing Recommendations

For maintenance therapy in adrenal insufficiency, adults should receive hydrocortisone 15-25 mg daily in divided doses (typically given as 10 mg upon waking, 5 mg at lunch, and 2.5-5 mg in early afternoon), while children require 2 mg/kg every 4-6 hours based on weight and clinical context. 1

Maintenance Therapy for Adrenal Insufficiency

Adults

• Primary adrenal insufficiency requires hydrocortisone 15-25 mg daily in 2-3 divided doses, with the largest dose given in the morning to mimic physiological cortisol rhythm. 1
• Add fludrocortisone 50-200 μg once daily for mineralocorticoid replacement in primary adrenal insufficiency only. 1
• Secondary adrenal insufficiency requires only glucocorticoid replacement (hydrocortisone 10-20 mg morning, 5-10 mg afternoon) without fludrocortisone. 1
• The FDA-approved dosing range is 20-240 mg daily depending on disease severity, though lower doses (15-25 mg) are preferred for chronic replacement to avoid overtreatment. 2

Children

• Weight-based dosing is essential: hydrocortisone 2 mg/kg administered every 4-6 hours depending on clinical stability. 3
• For maintenance, divide total daily dose into 2-3 administrations with morning-weighted dosing. 1

Stress Dosing for Illness

Minor Illness (fever, URI, gastroenteritis)

• Double the usual daily hydrocortisone dose until recovery, continuing for 24-48 hours after symptom resolution. 1
• Example: If baseline is 20 mg daily, increase to 40 mg daily in divided doses. 1

Moderate Illness (persistent vomiting, high fever >38.5°C)

• Triple the usual daily dose or use 2-3 times maintenance (e.g., hydrocortisone 30-50 mg total daily). 1
• Continue until illness resolves, then taper back to maintenance over 2-3 days. 1

Severe Illness or Adrenal Crisis

• Immediate hydrocortisone 100 mg IV or IM bolus without waiting for diagnostic testing. 1
• Follow with hydrocortisone 100 mg IV every 6-8 hours OR continuous infusion of 200-300 mg/24 hours. 3, 1
• Administer 1 liter of 0.9% saline IV over the first hour, then continue isotonic fluids at slower rate for 24-48 hours. 3
• Critical pitfall: Never delay treatment for diagnostic procedures—draw blood for cortisol and ACTH, then treat immediately. 1

Perioperative Management

Adults - Major Surgery

• Hydrocortisone 100 mg IV bolus at induction, followed immediately by continuous infusion of 200 mg/24 hours. 3, 1
• Alternative: Hydrocortisone 50 mg IV/IM every 6 hours if continuous infusion unavailable. 3
• Postoperatively, continue 200 mg/24 hours IV infusion while NPO, then transition to double oral dose for 48 hours once tolerating oral intake. 3, 1
• If recovery is complicated, continue doubled oral dose for up to one week before tapering. 3

Adults - Minor Surgery

• Hydrocortisone 100 mg IV/IM just before anesthesia. 3
• Double oral dose for 24 hours postoperatively, then return to maintenance. 3

Children - Major Surgery

• Hydrocortisone 2 mg/kg IV at induction, followed by weight-based continuous infusion: 3
  • Up to 10 kg: 25 mg/24 hours
  • 11-20 kg: 50 mg/24 hours
  • Over 20 kg prepubertal: 100 mg/24 hours
  • Pubertal: 150 mg/24 hours
• Postoperatively: Hydrocortisone 2 mg/kg every 4 hours IV/IM until stable, then double usual oral doses for 48 hours. 3

Children - Minor Procedures with General Anesthesia

• Hydrocortisone 2 mg/kg IV/IM at induction. 3
• Double normal doses for 24 hours once enteral feeding established. 3

Labour and Delivery

• Hydrocortisone 100 mg IV at onset of labour, followed by continuous infusion of 200 mg/24 hours. 3
• Alternative: Hydrocortisone 100 mg IM, then 50 mg IM every 6 hours. 3
• Double oral dose for 24-48 hours after delivery. 3

Special Populations

Patients on Chronic Corticosteroids (≥5 mg prednisone equivalent for ≥4 weeks)

• These patients require perioperative stress dosing identical to those with diagnosed adrenal insufficiency, as approximately one-third to one-half have suppressed HPA axis. 1, 4
• Use same protocols as outlined above for major/minor surgery. 3, 4

Conversion Equivalencies

• 20 mg hydrocortisone = 5 mg prednisone = 4 mg methylprednisolone. 1, 2
• This is critical for converting between formulations during transitions of care. 1

Critical Patient Education and Safety

Emergency Preparedness

• All patients must have emergency injectable hydrocortisone at home (typically 100 mg IM preparation). 1
• Wear medical alert bracelet or necklace identifying adrenal insufficiency. 1
• Carry written stress-dosing instructions at all times. 1

Recognition of Adrenal Crisis

• Teach patients to recognize: severe weakness, confusion, abdominal pain, persistent vomiting, hypotension. 1
• If unable to tolerate oral medications due to vomiting, patients should self-administer 100 mg IM hydrocortisone and seek emergency care immediately. 1

Common Pitfalls to Avoid

• Never use dexamethasone for long-term maintenance replacement in primary adrenal insufficiency—it lacks mineralocorticoid activity. 1
• Do not initiate thyroid hormone replacement before glucocorticoid replacement in hypopituitarism, as this precipitates adrenal crisis. 1
• Hydrocortisone requires multiple daily doses or continuous infusion for sustained effect—a single dose does NOT provide 24-hour coverage (unlike dexamethasone 6-8 mg which does). 5
• Patients on chronic inhaled corticosteroids at high doses may have HPA axis suppression and require stress dosing consideration. 3
• Diabetic patients may require 40-60% increase in insulin during stress-dose steroid coverage due to hyperglycemic effects. 4