What is the optimal dose of hydrocortisone for treating adrenal insufficiency?

From the Guidelines

The standard replacement dose of hydrocortisone for adrenal insufficiency is typically 15-25 mg per day, divided into multiple doses to mimic the body's natural cortisol rhythm, as recommended by the most recent and highest quality study 1.

Key Considerations

• A common regimen is 10-15 mg in the morning upon waking, 5-10 mg in the early afternoon (around 2 PM), and sometimes a smaller dose of 2.5-5 mg in the early evening if needed, as suggested by 1 and 1.
• This dosing schedule attempts to replicate the natural diurnal pattern of cortisol secretion, with higher levels in the morning and lower levels in the evening.
• Patients should take the morning dose immediately upon waking and the afternoon dose no later than 4-5 PM to avoid sleep disturbances.

Dose Adjustments

• During times of physical stress such as illness, injury, or surgery, patients need to increase their hydrocortisone dose, typically doubling or tripling the usual daily amount, as recommended by 1.
• For minor illness with fever, patients should double their dose for the duration of illness.
• For severe illness, major surgery, or trauma, intravenous hydrocortisone 100 mg every 6-8 hours may be necessary.

Additional Recommendations

• All patients should carry a steroid emergency card and wear medical alert identification.
• Dosing needs to be individualized based on clinical response, with adjustments made to control symptoms of both over-replacement (weight gain, insomnia, facial fullness) and under-replacement (fatigue, nausea, hypotension), as suggested by 1 and 1.
• Endocrine consultation should be part of planning before surgery or high-stress treatments, and patients should be educated on stress dosing for sick days, use of emergency injectables, and when to seek medical attention for impending adrenal crisis, as recommended by 1.

From the FDA Drug Label

In the treatment of acute exacerbations of multiple sclerosis, daily doses of 800 mg of hydrocortisone for a week followed by 320 mg every other day for one month are recommended The initial dose of SOLU-CORTEF Sterile Powder is 100 mg to 500 mg, depending on the specific disease entity being treated For pediatric patients, the initial dose of hydrocortisone may vary depending on the specific disease entity being treated. The range of initial doses is 0.56 to 8 mg/kg/day in three or four divided doses

The best dose of hydrocortisone for adrenal insufficiency is 100 mg to 500 mg, depending on the specific disease entity being treated 2.

• The dose may be repeated at intervals of 2,4, or 6 hours as indicated by the patient's response and clinical condition.
• Dosage requirements are variable and must be individualized on the basis of the disease under treatment and the response of the patient.
• In pediatric patients, the initial dose may vary depending on the specific disease entity being treated, with a range of 0.56 to 8 mg/kg/day in three or four divided doses 2.

From the Research

Dosing of Hydrocortisone for Adrenal Insufficiency

The dosing of hydrocortisone for adrenal insufficiency can vary depending on the specific circumstances, such as the severity of the condition and the presence of stress.

• For maintenance therapy, the recommended dose is 15-25 mg of hydrocortisone, divided into two or three separate doses 3.
• In cases of major stress, such as surgery or sepsis, a higher dose of hydrocortisone may be necessary to prevent adrenal crisis.
• A study found that continuous intravenous infusion of 200 mg hydrocortisone over 24 hours, preceded by an initial bolus of 50-100 mg hydrocortisone, was effective in maintaining cortisol concentrations in the required range 4.
• Another study recommended an initial bolus of 100 mg hydrocortisone, followed by 200 mg/24 h as continuous infusion or bolus of 50 mg every 6 h for the treatment of adrenal crisis 5.

Administration Modes

Different administration modes of hydrocortisone have been studied, including:

• Continuous intravenous infusion, which was found to be the most effective mode in achieving median cortisol concentrations in the range observed during major stress 4.
• Intermittent bolus administration, which may not be as effective in maintaining cortisol concentrations 4.
• Oral and subcutaneous formulations, which may be useful for long-term management of adrenal insufficiency 6.

Special Considerations

• Patients with adrenal insufficiency require careful and repeated education on dose adjustments and stress management to prevent adrenal crisis 5, 7.
• The availability of various glucocorticoid formulations and access to expert centers can vary widely, and European Reference Networks on rare endocrine conditions aim to harmonize treatment and ensure access to specialized patient care 6.