Cortef (Hydrocortisone) 10 mg in Adrenal Insufficiency
Cortef 10 mg serves as physiologic glucocorticoid replacement therapy to prevent life-threatening adrenal crisis in patients whose adrenal glands cannot produce adequate cortisol. 1
Primary Purpose and Mechanism
Hydrocortisone is the pharmaceutical form of cortisol, the body's naturally occurring glucocorticoid hormone. 1 In adrenal insufficiency, the adrenal glands fail to produce sufficient cortisol, creating a deficiency state that requires lifelong hormone replacement. 1 Hydrocortisone replaces this missing cortisol to maintain essential metabolic functions, immune responses, and cardiovascular stability. 1
Specific Clinical Indications
For mild to moderate adrenal insufficiency (Grade 1-2), the standard maintenance regimen is hydrocortisone 10-20 mg orally every morning, with 5-10 mg in early afternoon. 2 The 10 mg dose typically represents either:
- The morning dose component in a split-dosing regimen (e.g., 10 mg at 7 AM + 5 mg at noon + 2.5-5 mg at 4 PM) 3
- Part of a total daily dose of 15-25 mg divided to approximate physiological cortisol secretion 3, 4
Dosing Strategy Based on Severity
The hydrocortisone dose must be adjusted based on clinical severity:
- Asymptomatic/mild symptoms (G1): 10-20 mg morning, 5-10 mg early afternoon 2
- Moderate symptoms (G2): 20-30 mg morning, 10-20 mg afternoon (2-3 times maintenance) 2
- Severe symptoms/crisis (G3-4): 100 mg IV hydrocortisone immediately, not oral tablets 2
Critical Distinction: Primary vs. Secondary Adrenal Insufficiency
Primary adrenal insufficiency requires both glucocorticoid AND mineralocorticoid replacement (fludrocortisone 0.1 mg/day), while secondary adrenal insufficiency requires only glucocorticoid replacement. 2, 3 The 10 mg hydrocortisone dose addresses only the glucocorticoid deficiency. 2
Why This Specific Dose Matters
Hydrocortisone 10 mg approximates the physiological cortisol secretion pattern when given as the morning dose, as cortisol naturally peaks upon awakening. 3 The goal is to provide the lowest dose compatible with health and well-being, avoiding both under-replacement (fatigue, nausea, hypotension) and over-replacement (weight gain, insomnia, hypertension). 3
However, conventional immediate-release hydrocortisone tablets cannot perfectly replicate the normal diurnal cortisol rhythm, and most patients remain imperfectly treated relative to physiological cortisol concentrations. 5, 6 Studies show that 79% of patients at 8 AM and 55% at 4 PM are either over- or under-treated with standard regimens. 6
Essential Patient Education for Safe Use
All patients on hydrocortisone for adrenal insufficiency must:
- Wear a medical alert bracelet indicating adrenal insufficiency to trigger emergency stress-dose corticosteroids 2, 3
- Double or triple the dose during illness, fever, or infection 3, 4
- Carry emergency injectable hydrocortisone 100 mg IM with self-injection training 3, 4
- Seek immediate emergency care for vomiting or severe illness, as inability to take oral medication necessitates IV hydrocortisone 3
Common Pitfalls to Avoid
Never delay treatment of suspected adrenal crisis to perform diagnostic testing—mortality is high if untreated, and immediate IV hydrocortisone 100 mg plus saline infusion must be given. 2, 7
Do not assume the absence of hyperkalemia rules out adrenal insufficiency—it occurs in only 50% of cases. 7, 4
When treating concurrent hypothyroidism and adrenal insufficiency, always start corticosteroids several days before thyroid hormone to prevent precipitating adrenal crisis. 2
Certain medications increase hydrocortisone requirements (anticonvulsants, rifampin, topiramate), while others decrease requirements (grapefruit juice, licorice)—dose adjustments are necessary. 3
Monitoring and Dose Titration
Clinical assessment, not cortisol levels, guides dose adjustment in patients on established replacement therapy. 3 Signs requiring dose increase include persistent fatigue, nausea, weight loss, and orthostatic hypotension. 3 Signs of over-replacement requiring dose reduction include weight gain, insomnia, hypertension, and peripheral edema. 3
Endocrine consultation is mandatory for newly diagnosed patients, pre-operative planning, and any patient with recurrent adrenal crises. 2