What is the appropriate hydrocortisone dose for an adult patient?

Hydrocortisone Dosing in Adults

For daily physiological replacement in primary adrenal insufficiency, most adults should receive 15-25 mg of hydrocortisone per day in split doses, with the first dose immediately upon waking and the last dose at least 6 hours before bedtime. 1

Daily Maintenance Dosing

• Standard replacement dose: 15-25 mg hydrocortisone daily (equivalent to 18.75-31.25 mg cortisone acetate), divided into 2-3 doses throughout the day 1
• The first dose should be taken immediately upon awakening, with the final dose administered no less than 6 hours before bedtime to mimic physiological cortisol rhythm 1
• Use the lowest dose compatible with health and sense of well-being to minimize long-term glucocorticoid complications 1
• Dosing should be based on body surface area: normal adrenal function produces 5-10 mg cortisol per m² of body surface area daily 1

Stress Dosing for Surgery and Major Illness

For patients undergoing surgery or experiencing major physiological stress, administer hydrocortisone 100 mg intravenously at induction, followed immediately by continuous infusion of 200 mg over 24 hours. 1

Peri-operative Management

• Intra-operative: Hydrocortisone 100 mg IV bolus at induction, then 200 mg/24 hours as continuous IV infusion 1
• Alternative to infusion: Hydrocortisone 50 mg IV or IM every 6 hours (total 200 mg/day) if continuous infusion is impractical 1
• Postoperative: Continue 200 mg/24 hours IV infusion until patient can take oral medications 1
• Transition to oral: Double the usual oral hydrocortisone dose for 48 hours after uncomplicated surgery, or up to one week following major surgery 1

The continuous infusion regimen is strongly preferred because it is the only administration mode that persistently achieves median cortisol concentrations in the range observed during major stress 2

Adrenal Crisis Management

For suspected or confirmed adrenal crisis, immediately administer hydrocortisone 100 mg IV or IM, followed by 100 mg every 6-8 hours until recovery. 1

• Do not delay treatment for diagnostic procedures when adrenal crisis is suspected 1
• Administer 1 liter of 0.9% sodium chloride solution initially at 1 L/hour until hemodynamic improvement 1
• Continue stress dosing (400 mg/day total) until the patient has recovered from the acute illness 1

Special Populations and Situations

Septic Shock

• Hydrocortisone 200 mg/day administered as either continuous infusion (240 mg/day or 10 mg/hour) or in four divided doses (50 mg every 6 hours) for ≥7 days 3
• Treatment should be continued for at least 7 days and weaned gradually rather than stopped abruptly 3

Labor and Delivery

• Hydrocortisone 100 mg IV at onset of labor, followed by continuous infusion of 200 mg/24 hours 1
• Alternative: Hydrocortisone 100 mg IM followed by 50 mg every 6 hours IM 1

Patients on Chronic Therapeutic Glucocorticoids

• For those receiving prednisolone ≥5 mg daily for ≥4 weeks undergoing major surgery: same stress dosing as primary adrenal insufficiency (100 mg IV bolus, then 200 mg/24 hours infusion) 1

Important Clinical Considerations

• Monitoring: Clinical assessment is the primary method for dose adjustment; plasma ACTH and serum cortisol are not useful for routine dose titration 1
• Signs of over-replacement: Weight gain, insomnia, peripheral edema, hypertension 1
• Signs of under-replacement: Lethargy, nausea, poor appetite, weight loss, increased pigmentation 1
• Drug interactions: CYP3A4 inducers and inhibitors significantly affect hydrocortisone clearance and may require dose adjustments 1

The FDA-approved dosage range for hydrocortisone is 20-240 mg per day depending on the specific disease entity, with dosage requirements being highly variable and individualized 4. However, for adrenal insufficiency specifically, the consensus guidelines provide more precise recommendations as outlined above.