What is the equivalent oral hydrocortisone (corticosteroid) tablet dose for an adult patient with a normal body mass index and no significant renal (kidney) or hepatic (liver) impairment, currently taking hydrocortisone 50mg twice daily?

Conversion of Hydrocortisone 50mg Twice Daily to Oral Tablet

Direct Answer

A patient taking hydrocortisone 50mg twice daily (100mg total daily dose) is receiving approximately 4-5 times the recommended physiological replacement dose and should be tapered down to a maintenance dose of 15-25mg daily in divided doses, typically 10mg upon awakening, 5mg at noon, and 2.5-5mg in early afternoon. 1

Understanding the Current Dose

Your patient is currently receiving 100mg daily of hydrocortisone, which far exceeds physiological replacement needs:

• Standard maintenance dosing for adrenal insufficiency is 15-25mg daily in divided doses 1
• The current 100mg daily dose represents a stress-dose or acute illness regimen, not maintenance therapy 1, 2
• This dose is appropriate only for acute adrenal crisis, major surgery, or severe illness requiring 2-3 times maintenance dosing 1

Recommended Conversion Protocol

Step 1: Assess Clinical Context

Determine why the patient is on this high dose:

• If recovering from acute stress/surgery: Transition using the stress-dose taper protocol 2
• If this is chronic dosing: Immediate reduction to maintenance is appropriate 1
• If unclear indication: Assume stress dosing and taper conservatively 1

Step 2: Transition to Maintenance Dosing

For post-stress transition (most common scenario):

• Continue 50mg twice daily for 48 hours post-stress 2
• Then reduce to double maintenance (30-40mg daily) for an additional 48 hours 2
• Finally, establish maintenance dosing at 15-25mg daily 1

For direct conversion (if chronically overdosed):

• Immediately reduce to 15-25mg daily in divided doses 1
• Most common regimen: 10mg at 0700h, 5mg at 1200h, 2.5-5mg at 1600h 1
• Alternative two-dose regimen: 15mg at 0700h, 5-10mg at 1200h 1

Step 3: Specific Dosing Schedules

Three-dose regimen (preferred for mimicking diurnal rhythm):

• 10mg upon awakening (0700h) 1
• 5mg at midday (1200h ±1 hour) 1
• 2.5-5mg in early afternoon (1600h ±1 hour) 1

Two-dose regimen (for compliance issues):

• 15mg upon awakening (0700h) 1
• 5-10mg at midday (1200h ±1 hour) 1

Critical Pitfalls to Avoid

Do not use long-acting steroids as first-line replacement:

• Dexamethasone should be avoided for maintenance therapy 1
• Prednisolone (4-5mg daily) may be considered only for marked fluctuations in energy or compliance problems 1
• Hydrocortisone 20mg is equivalent to prednisolone 5mg 1, 3

Monitor for under-replacement:

• Salt craving, lightheadedness, or orthostatic hypotension indicate need for fludrocortisone 1
• Most primary adrenal insufficiency requires fludrocortisone 0.05-0.1mg daily 1
• Under-replacement predisposes to recurrent adrenal crises 1

Monitor for over-replacement:

• Symptoms include bruising, thin skin, edema, weight gain, hypertension, hyperglycemia 1
• Reduce maintenance dosing if iatrogenic Cushing's syndrome develops 1
• Maximum maintenance dose should not exceed 30mg daily 1

Mineralocorticoid Considerations

If primary adrenal insufficiency:

• Add fludrocortisone 0.05-0.1mg once daily upon awakening 1
• Titrate based on volume status, sodium level, and renin (target upper half of reference range) 1
• Avoid diuretics, NSAIDs, and drospirenone-containing contraceptives 1

If secondary adrenal insufficiency (low ACTH with low cortisol):

• Fludrocortisone is typically not required 1
• Mineralocorticoid axis remains intact in pituitary/hypothalamic disease 1

Patient Education Requirements

All patients require education on:

• Stress dosing for sick days (double or triple the dose) 1
• Emergency injectable hydrocortisone use 1
• When to seek medical attention for impending adrenal crisis 1
• Medical alert bracelet or necklace for adrenal insufficiency 1

Stress-dose guidelines:

• Minor illness: Double the usual dose for 2-3 days 1
• Major illness/surgery: Hydrocortisone 50-100mg IV every 6-8 hours 1, 2
• Taper stress doses down to maintenance over 5-7 days 1

Monitoring and Follow-up

Clinical monitoring parameters:

• Blood pressure (supine and standing) 1
• Electrolytes (sodium, potassium) 1
• Weight and signs of Cushing's syndrome 1
• Symptoms of under-replacement (fatigue, salt craving) 1

Endocrinology consultation is appropriate for:

• Establishing initial diagnosis and dosing 1
• Planning before surgery or high-stress treatments 1
• Difficulty achieving stable replacement 1