In patients with primary or secondary adrenal insufficiency, what are the recommended hydrocortisone stress‑dose regimens (dose and frequency) for mild, moderate, and severe stress, including pediatric weight‑based dosing and dexamethasone alternatives?

Stress Dose Hydrocortisone Regimens for Adrenal Insufficiency

For severe stress (major surgery, sepsis, adrenal crisis), administer hydrocortisone 100 mg IV bolus immediately, followed by continuous IV infusion of 200 mg over 24 hours—this is superior to intermittent bolus dosing for maintaining physiologic cortisol levels during major stress. 1, 2, 3

Stress Dosing by Severity

Severe Stress (Adrenal Crisis, Major Surgery, Sepsis)

• Immediate treatment: Hydrocortisone 100 mg IV or IM bolus without delay for diagnostic testing 2, 4
• Maintenance: Continuous IV infusion of 200 mg hydrocortisone over 24 hours is the preferred method, as it is the only administration mode that persistently achieves median cortisol concentrations in the range observed during major stress 1, 3
• Alternative regimen: If continuous infusion is not feasible, give hydrocortisone 100 mg IV every 6-8 hours (total 300-400 mg/24h), though this produces suboptimal cortisol profiles compared to continuous infusion 2, 3
• Concurrent therapy: Administer IV isotonic sodium chloride solution at 1 L/hour (at least 2L total) 2
• Duration: Continue stress dosing until the patient is clinically stable and recovering, then transition to oral doubled dose 1

Moderate Stress (Moderate Illness, Minor Surgery)

• Outpatient management: Triple the usual daily maintenance dose or use 2-3 times maintenance dose 2
• Specific dosing: Hydrocortisone 30-50 mg total daily in divided doses (e.g., if usual dose is 10-5-5 mg, give 30-15-15 mg) 2
• Duration: Continue for 5-10 days, then taper back to maintenance dose as symptoms improve 2
• For minor surgery: Hydrocortisone 50-75 mg daily in divided doses 2

Mild Stress (Minor Illness, Fever, Dental Procedures)

• Dosing: Double the usual daily maintenance dose 2
• Example: If usual dose is 10-5-5 mg hydrocortisone, give 20-10-10 mg 1
• Duration: Continue doubled dose for 24-48 hours after symptoms resolve 2

Perioperative Stress Dosing

Major Surgery

• Induction: Hydrocortisone 100 mg IV bolus at start of surgery 1, 2
• Intraoperative/postoperative: Continuous IV infusion of 200 mg over 24 hours 1, 2
• Recovery phase: If uncomplicated recovery, double the regular oral replacement dose for 48 hours to 1 week postoperatively before resuming maintenance 1
• Prolonged critical illness: Continue stress-dose IV infusion until patient is stable and recovering 1

Minor Surgery

• Dosing: Double the usual daily dose for 1-2 days 2

Pediatric Weight-Based Dosing

• Severe stress/crisis: Hydrocortisone 2 mg/kg IV at induction or immediately, followed by weight-based continuous infusion 2
• Frequency: Administer every 4-6 hours depending on clinical stability 2
• Major surgery: Hydrocortisone 2 mg/kg IV bolus at induction, followed by weight-based continuous infusion 2

Dexamethasone as Alternative

• Equivalency: Dexamethasone 8 mg is equivalent to approximately 200 mg hydrocortisone 1, 2
• Duration: Provides adequate coverage for 24 hours due to long-acting properties 1
• Critical limitation: Dexamethasone has NO mineralocorticoid activity and is inadequate for primary adrenal insufficiency—never use as sole agent in primary AI 1, 2
• Specific indication: Use dexamethasone 4 mg IV only when you need to treat suspected adrenal crisis but still want to perform diagnostic testing later, as it does not interfere with cortisol assays 2

Critical Pitfalls to Avoid

• Never delay treatment of suspected adrenal crisis for diagnostic procedures—mortality is high if untreated 1, 2, 4
• Avoid intermittent bolus dosing during severe stress when continuous infusion is available, as bolus administration (even every 6 hours) produces suboptimal cortisol profiles with peaks and troughs 3
• Do not use dexamethasone for primary adrenal insufficiency stress dosing, as it lacks mineralocorticoid activity 1, 2
• Medication errors and omissions on hospital wards are a documented cause of adrenal crisis—ensure stress dosing is not interrupted 1
• Patients on CYP3A4 inducers (anticonvulsants, rifampin) may require higher doses due to increased cortisol clearance 1, 2

Patient Education Requirements

• All patients must receive explicit stress-dosing instructions and possess emergency injectable hydrocortisone 100 mg IM kit with self-injection training 2, 4
• Patients must wear medical alert bracelet or necklace indicating adrenal insufficiency 2, 4
• Educate on recognition of adrenal crisis symptoms: severe weakness, confusion, abdominal pain, vomiting, hypotension 2