Maximum Daily Dose of Hydrocortisone Injection
The maximum daily dose of hydrocortisone injection depends entirely on the clinical context: for maintenance therapy in adrenal insufficiency, use 15-25 mg daily in divided doses; for adrenal crisis, use 100 mg IV/IM immediately followed by 100 mg every 6-8 hours (300-400 mg/day) until recovery; for septic shock, use 200 mg/day as continuous infusion or divided doses for at least 3 days. 1, 2
Context-Specific Maximum Dosing
Maintenance Replacement Therapy
- Standard daily dose: 15-25 mg total per day in divided doses 1, 3, 4
- Administer as 10 mg upon awakening, 5 mg at midday, and 2.5-5 mg in early afternoon for three-dose regimen 3
- Alternative two-dose regimen: 15 mg upon awakening and 5-10 mg at midday 3
- Use the lowest dose compatible with health and sense of well-being 1
Adrenal Crisis (Life-Threatening Emergency)
- Initial dose: 100 mg IV or IM immediately without waiting for diagnostic confirmation 1, 2
- Maintenance: 100 mg IV/IM every 6-8 hours until recovered (300-400 mg/day total) 1
- Continue full-dose therapy for at least 3-5 days before considering taper 2
- Never delay treatment for diagnostic procedures—mortality is high if untreated 2
Septic Shock (Vasopressor-Dependent)
- Maximum recommended dose: 200 mg/day (not exceeding 400 mg/day) 2
- Administer as continuous infusion of 200 mg/24 hours or as 50 mg IV every 6 hours 2
- Use only when adequate fluid resuscitation and moderate-to-high dose vasopressors fail to restore hemodynamic stability 4, 2
- Continue for at least 3 days at full dose before initiating taper 2
- Critical guideline: doses <400 mg/day for ≥3 days are recommended by the Society of Critical Care Medicine 2
Perioperative/Major Surgery
- Induction dose: 100 mg IV at surgical induction 2
- Maintenance: 200 mg/24 hours as continuous infusion 2
- Continue IV infusion while nil by mouth or if postoperative vomiting occurs 2
- Resume oral dosing at double the usual replacement dose for 48 hours after uncomplicated surgery, or up to one week following major surgery 2
Critical Dosing Principles
Upper Limit Considerations
- The 400 mg/day threshold is the evidence-based upper limit for septic shock management 2
- Doses exceeding usual dosages may be justified only in overwhelming, acute, life-threatening situations 2
- For stress dosing in minor illness, double the usual maintenance dose for 2-3 days 4
- For major illness, use 50-100 mg IV every 6-8 hours 4
Common Pitfalls to Avoid
- Do not use maintenance doses (15-25 mg/day) for acute adrenal crisis—this is inadequate and potentially fatal 1
- Avoid abrupt discontinuation after high-dose therapy; taper gradually over 6-14 days to prevent rebound inflammation 2
- Do not exceed 400 mg/day in septic shock, as higher doses provide no additional benefit and increase adverse effects 2
- Never delay emergency treatment (100 mg IV/IM) while waiting for diagnostic confirmation in suspected adrenal crisis 1, 2