What is the recommended dosing of Solucortef (hydrocortisone) for a patient with adrenal insufficiency?

Solucortef (Hydrocortisone) Dosing for Adrenal Insufficiency

For adrenal crisis, immediately administer Solucortef 100 mg IV or IM without delay, followed by 100 mg every 6-8 hours until recovery, along with aggressive IV fluid resuscitation. 1, 2, 3

Dosing by Clinical Scenario

Acute Adrenal Crisis (Life-Threatening)

• Immediate bolus: 100 mg IV or IM hydrocortisone without waiting for diagnostic confirmation 1, 2, 4
• Maintenance during crisis: 100 mg IV every 6-8 hours OR continuous infusion of 200-300 mg/24 hours until clinical recovery 1, 2, 3
• Fluid resuscitation: Isotonic (0.9%) sodium chloride solution at 1 L/hour initially until hemodynamic improvement 1
• Duration: Continue high-dose therapy only until patient stabilizes, usually not beyond 48-72 hours 3

Critical pitfall: Never delay treatment for diagnostic testing—draw blood for cortisol and ACTH, then treat immediately. 2, 4

Maintenance Therapy (Chronic Replacement)

Primary Adrenal Insufficiency

• Hydrocortisone: 15-25 mg daily in split doses 1, 2
  • Typical regimen: 10 mg upon awakening + 5 mg at noon + 2.5-5 mg in early afternoon (last dose at least 6 hours before bedtime) 1
  • Alternative two-dose regimen: 15 mg + 5 mg OR 10 mg + 10 mg 1
• Fludrocortisone: 50-200 μg as single daily dose (children and young adults may require up to 500 μg) 1, 2, 4
• Pediatric dosing: 6-10 mg/m² body surface area daily 1

Secondary Adrenal Insufficiency

• Hydrocortisone only: 10-20 mg morning + 5-10 mg afternoon 2
• No mineralocorticoid replacement needed 2

Stress Dosing for Illness

Algorithm by severity:

• Minor illness (fever, URI): Double usual daily dose until recovery, continue doubled dose 24-48 hours after symptoms resolve 2, 4
• Moderate illness (persistent vomiting, high fever): Triple usual dose OR 30-50 mg total daily (alternative: prednisone 20 mg daily) 2, 4
• Severe illness/inability to take oral: Immediate IV/IM hydrocortisone 100 mg, then 100 mg every 6-8 hours 1, 2

Perioperative Management

Major Surgery

• At induction: 100 mg IV hydrocortisone 2, 4, 3
• Intraoperatively: Continuous infusion 200 mg/24 hours 2, 4
• Postoperatively: Continue 200 mg/24 hours IV while NPO, then transition to oral double usual dose for 48 hours after uncomplicated recovery 2

Minor Procedures

• Preoperative: Double oral dose on day of procedure 2

Labor and Delivery

• At onset of labor: 100 mg IV hydrocortisone 2
• During labor: Continuous infusion 200 mg/24 hours 2
• Postpartum: Double oral dose for 48 hours after delivery 2

Preparation and Administration

From FDA label: 3

• For 100 mg vial: Add not more than 2 mL Bacteriostatic Water for Injection
• IV injection: Administer over 30 seconds (100 mg) to 10 minutes (500 mg or more)
• IV infusion: After reconstitution, may add to 100-1000 mL of 5% dextrose in water or isotonic saline
• IM injection: Use same reconstitution as IV

Monitoring and Dose Adjustment

Clinical assessment is primary monitoring method: 1, 4

• Over-replacement signs: Weight gain, insomnia, peripheral edema, hypertension 1, 4
• Under-replacement signs: Lethargy, nausea, poor appetite, weight loss, increased pigmentation 1, 4

For fludrocortisone titration: Target normotension, normokalemia, and plasma renin in upper half of normal range 4

Drug Interactions Requiring Dose Adjustment

Medications that increase hydrocortisone requirements: 1, 4

• Anti-epileptics/barbiturates
• Rifampin (antituberculosis)
• Topiramate
• Etomidate

Medications that decrease requirements: 1

• Grapefruit juice
• Liquorice

Essential Patient Education

All patients must: 1, 2, 4

• Wear medical alert identification jewelry
• Carry steroid emergency card
• Possess emergency injectable hydrocortisone at home with explicit instructions
• Understand stress dosing protocols
• Know adrenal crisis symptoms: severe weakness, confusion, abdominal pain, vomiting, hypotension

Critical pitfall: In patients with hypopituitarism, never initiate thyroid hormone replacement before adrenal replacement, as this can precipitate adrenal crisis. 2

Special Populations

Pediatric weight-based dosing for crisis: 2 mg/kg IV every 4-6 hours depending on clinical stability 2

Pregnancy: May need dose adjustments during last trimester; fludrocortisone may require increase up to 500 μg daily due to progesterone antagonism 1, 2

Chronic exogenous steroid users: Patients receiving prednisolone equivalent ≥5 mg for ≥4 weeks require perioperative stress dosing even without diagnosed adrenal insufficiency 2