Can You Start Hydrocortisone for This Patient?
Yes, you can start hydrocortisone, but the decision depends entirely on the specific clinical indication—whether this patient has adrenal insufficiency (primary or secondary), immune checkpoint inhibitor-related adrenal toxicity, septic shock with refractory hypotension, or requires perioperative stress-dose coverage.
Clinical Context Determines Dosing and Indication
For Adrenal Insufficiency (Primary or Secondary)
If your patient has confirmed or suspected adrenal insufficiency, initiate hydrocortisone immediately without waiting for diagnostic confirmation if they are clinically unstable. 1
Grade 1 (Asymptomatic or Mild Symptoms):
- Start hydrocortisone 15-20 mg daily in divided doses (typically 10-15 mg in morning, 5-10 mg early afternoon to mimic diurnal rhythm) 1
- Titrate up to maximum 30 mg daily if residual symptoms persist 1
- For primary adrenal insufficiency, add fludrocortisone 0.05-0.1 mg daily once diagnosis confirmed (adjust based on volume status, sodium, and renin levels targeting upper half of reference range) 1
- Consider holding immune checkpoint inhibitors until patient stabilized on replacement hormones 1
Grade 2 (Moderate Symptoms, Able to Perform ADL):
- Initiate outpatient corticosteroid at 2-3 times maintenance dose: hydrocortisone 30-50 mg total daily or prednisone 20 mg daily 1
- Add fludrocortisone 0.05-0.1 mg daily 1
- Decrease stress-dose corticosteroids to maintenance after 2 days 1
- Assess need for IV hydration, supportive care, and potential hospitalization 1
Grade 3-4 (Severe/Life-Threatening, Unable to Perform ADL):
- Administer IV stress-dose steroids immediately: hydrocortisone 50-100 mg IV every 6-8 hours 1
- Provide aggressive fluid resuscitation with at least 2L normal saline 1
- Taper stress-dose corticosteroids to oral maintenance over 5-7 days 1
- Hold immune checkpoint inhibitors until stabilized 1
Critical pitfall: If you suspect adrenal crisis and need to perform ACTH stimulation testing, use dexamethasone 4 mg IV instead of hydrocortisone for initial treatment, as it won't interfere with the cortisol assay 1. However, if diagnosis already confirmed, hydrocortisone 100 mg IV is preferred 1.
For Septic Shock
Only start hydrocortisone if adequate fluid resuscitation and vasopressor therapy have failed to restore hemodynamic stability. 1
Specific Criteria:
- Patient requires vasopressor support (typically norepinephrine ≥0.25 mcg/kg/min for at least 4 hours) despite adequate fluid resuscitation 2
- Hemodynamic instability persists after initial resuscitation 1
Dosing for Septic Shock:
- Hydrocortisone 200 mg/day by continuous IV infusion (preferred method) 1
- Alternative: Hydrocortisone 50 mg IV every 6 hours 1, 3
- Alternative regimen: Hydrocortisone 100 mg IV every 12 hours (shown non-inferior in recent studies, may reduce waste and cost) 3
- Do NOT use ACTH stimulation test to decide who receives hydrocortisone 1
- Taper hydrocortisone when vasopressors no longer required 1
- Do NOT administer corticosteroids for sepsis in the absence of shock 1
Evidence nuance: A 2018 RCT demonstrated that 100 mg/day hydrocortisone resulted in significantly lower hyperglycemia rates (63.9% vs 86.5%) compared to 200 mg/day, with shorter time to shock reversal and comparable mortality 4. A 2025 study confirmed no difference in time to shock reversal between every-12-hour and every-6-hour dosing 3. However, the Surviving Sepsis Campaign guidelines still recommend 200 mg/day as the standard dose 1.
Timing matters: Early initiation (≤3 hours) reduced time to discontinue vasopressors (25 vs 37 hours, p=0.009) compared to late initiation, though ICU mortality and length of stay were comparable 2.
For Perioperative Stress-Dose Coverage
If your patient has known adrenal insufficiency or is on chronic corticosteroids (≥5 mg prednisone equivalent for ≥4 weeks), provide stress-dose coverage for surgery. 1, 5, 6
Major Surgery Protocol:
- Hydrocortisone 100 mg IV at induction, followed immediately by continuous infusion of 200 mg/24 hours 1, 5, 6
- Alternative: Hydrocortisone 50 mg IV/IM every 6 hours 1, 5
- Alternative: Dexamethasone 6-8 mg IV at induction (provides 24-hour coverage but lacks mineralocorticoid activity—inadequate for primary adrenal insufficiency) 1, 7, 6
- Postoperatively: Continue hydrocortisone 200 mg/24 hours IV infusion while NPO, then transition to double oral maintenance dose for 48 hours once tolerating PO 1, 5, 6
Intermediate/Minor Surgery:
- Hydrocortisone 100 mg IV/IM at start of procedure 1
- Postoperatively: Double oral dose for 24-48 hours, then return to maintenance 1, 5
Labor and Vaginal Delivery:
- Hydrocortisone 100 mg IV at onset of labor, followed by continuous infusion 200 mg/24 hours 1
- Alternative: Hydrocortisone 100 mg IM, then 50 mg IM every 6 hours 1
Critical pitfall: For primary adrenal insufficiency, dexamethasone alone is insufficient perioperatively due to lack of mineralocorticoid activity—you must use hydrocortisone or add fludrocortisone 6.
For Immune Checkpoint Inhibitor-Related Adrenal Toxicity
If your patient is on immune checkpoint inhibitors and develops adrenal insufficiency, follow the graded approach above based on symptom severity. 1
- Distinguish primary from secondary adrenal insufficiency by ACTH/cortisol relationship: low ACTH with low cortisol indicates secondary (central) adrenal insufficiency from hypophysitis 1
- Always start corticosteroids several days before initiating thyroid hormone replacement to prevent precipitating adrenal crisis 1
- All patients need education on stress dosing, emergency injectable hydrocortisone, and medical alert bracelet 1
Key Monitoring and Safety Considerations
Hyperglycemia Risk:
- Monitor blood glucose closely, especially in diabetic patients—expect 40-60% or greater increase in insulin requirements with stress-dose steroids 6
- Lower hydrocortisone doses (100 mg/day vs 200 mg/day) significantly reduce hyperglycemia incidence 4
Transition from IV to Oral:
- Use 1:1 dose equivalence when transitioning 5
- Double usual maintenance dose for 48 hours post-stress, then return to standard maintenance (15-25 mg/day in divided doses) 5
- Ensure patient can tolerate oral intake before discontinuing IV therapy 5
Dose Equivalencies:
- Hydrocortisone 20 mg = Prednisone 5 mg 1, 6
- Dexamethasone 6-8 mg IV = Hydrocortisone 200 mg (24-hour coverage) 7, 6