What is the recommended tapering schedule for a patient with adrenal insufficiency who has been on long-term hydrocortisone (cortisol) therapy?

Hydrocortisone Tapering in Adrenal Insufficiency

After stress-dose hydrocortisone, taper over 1-3 days by reducing to double the usual maintenance dose for 24-48 hours, then return to standard physiologic replacement of 15-25 mg daily divided into 2-3 doses. 1, 2

Post-Acute Illness or Adrenal Crisis Tapering

The most straightforward approach is rapid tapering over 1-3 days when the precipitating illness has resolved:

• Continue parenteral hydrocortisone 100 mg IV/IM every 6 hours (or 200 mg/24h continuous infusion) until the patient can eat and drink 1
• Once oral intake is established, give double the normal oral maintenance dose for 24-48 hours 1, 2
• Then return directly to standard maintenance dosing of 15-25 mg daily 2, 3
• Restart fludrocortisone when hydrocortisone dose falls below 50 mg/day, as higher doses provide sufficient mineralocorticoid effect 1

Post-Surgical Tapering Protocol

Major surgery requires a more structured approach:

• Administer 100 mg hydrocortisone IV/IM immediately before anesthesia 1, 4
• Continue 100 mg hydrocortisone IV/IM every 6 hours until able to eat and drink 1, 2
• Once enteral intake established, give double the normal oral dose for 48+ hours 1, 2
• Then taper to standard maintenance doses 2, 4

Minor surgery requires less aggressive tapering:

• Give double the normal oral dose for 24-48 hours postoperatively 2
• Return to normal daily dosing once stable 2

Immune-Related Adverse Events (Checkpoint Inhibitor Therapy)

For patients with immune-related adrenal insufficiency on high-dose corticosteroids:

• Grade 2 (moderate symptoms): Taper stress-dose corticosteroids down to maintenance over 5-10 days 2
• Grade 3-4 (severe symptoms): Taper stress-dose corticosteroids down to maintenance over 7-14 days after discharge 2
• When tapering from prednisone 1-2 mg/kg/day, taper over 1-2 weeks down to physiologic maintenance equivalent to hydrocortisone 15-20 mg daily in divided doses 1, 2

Standard Maintenance Dosing Target

All tapering should end at physiologic replacement doses:

• Total daily dose: 15-25 mg hydrocortisone 2, 3, 5
• Three-dose regimen (preferred): 10 mg at 07:00 + 5 mg at 12:00 + 2.5-5 mg at 16:00 2
• Two-dose regimen (acceptable): 15 mg at 07:00 + 5 mg at 12:00, or 10 mg at 07:00 + 10 mg at 12:00 2
• Give the largest dose upon awakening and the last dose at least 6 hours before bedtime 3

Critical Monitoring During Tapering

Clinical assessment is the primary monitoring tool, as biochemical markers are unreliable: 2

Signs of over-replacement to watch for:

• Weight gain, insomnia, peripheral edema 2

Signs of under-replacement (impending adrenal crisis):

• Lethargy, fatigue, weakness, nausea, vomiting, poor appetite, weight loss 2
• Hypotension, hyponatremia, hyperkalaemia 1

Practical monitoring approach:

• Question patients about daily energy levels, "get up and go," mental concentration, and daytime somnolence 2
• Ask about low points or dips in energy during the day 2
• Assess ease of falling asleep at bedtime 2

Common Pitfalls and How to Avoid Them

Tapering too rapidly precipitates adrenal crisis, which can be life-threatening: 2

• Never stop hydrocortisone abruptly after more than 14 days of therapy 5
• HPA axis suppression may persist for months after discontinuation, requiring stress-dose coverage during any stressful situation in that period 5, 2
• The FDA label emphasizes that if long-term therapy is to be stopped, it must be withdrawn gradually rather than abruptly 5

Failure to restart mineralocorticoid replacement:

• Fludrocortisone should be restarted when hydrocortisone dose falls below 50 mg/day 1
• Typical dose is 50-200 μg once daily 3

Inadequate patient education:

• All patients require education on stress dosing for sick days, use of emergency steroid injectables, and when to seek medical attention for impending adrenal crisis 1, 2
• Medical alert identification for adrenal insufficiency is mandatory 1, 2
• Provide emergency injectable hydrocortisone and train a companion in its use 2

Special Considerations

Post-delivery tapering:

• After uncomplicated vaginal delivery or cesarean section, perform rapid tapering over 1-3 days from stress-dose hydrocortisone back to regular replacement dose 2

Recurrent illness during tapering:

• If the patient develops fever, infection, or other stress during tapering, immediately return to stress-dose coverage 3
• The frequency of adrenal crises is 6-8 per 100 patient-years, with infections being the major precipitating cause 1, 6