Explain hydrocortisone dosing
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hydrocortisone dosing AND adrenal insufficiency
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I now have comprehensive information from multiple authoritative sources. Here is a thorough breakdown of hydrocortisone dosing across all clinical contexts:
Hydrocortisone Dosing
Hydrocortisone (cortisol) is the preferred glucocorticoid for replacement therapy because it most closely mimics endogenous cortisol. Dosing varies significantly by indication, severity, and patient age.
1. Chronic Adrenal Insufficiency (Maintenance Replacement)
The goal is the lowest dose that relieves symptoms while avoiding Cushing features and osteoporosis.
| Route | Dose | Schedule |
|---|---|---|
| Oral (adults) | 15-25 mg/day (range 20-30 mg/day) | Divided doses |
| Typical split | 10 mg morning + 5 mg afternoon/evening | ~2/3 AM, ~1/3 PM |
- The morning dose is taken first thing on waking to mimic the physiologic cortisol surge.
- An optional third dose (~5 mg) in the early afternoon can reduce fatigue.
- Most adults are optimized between 4-7.5 mg/day prednisone equivalent if using that instead.
- Mineralocorticoid replacement (fludrocortisone 0.05-0.2 mg/day) is added for primary adrenal insufficiency once the hydrocortisone dose is under 50 mg/day, since high-dose hydrocortisone provides sufficient mineralocorticoid activity at higher doses.
Sources: Goodman & Gilman's Pharmacological Basis of Therapeutics; Washington Manual of Medical Therapeutics; Harrison's Principles of Internal Medicine 22E (2025)
2. Adrenal Crisis (Acute Emergency)
Act immediately - do not delay treatment for testing.
If diagnosis is already known:
- Hydrocortisone 100 mg IV every 8 hours
- 0.9% saline + 5% dextrose infused rapidly until hypotension corrects
- Taper the IV dose gradually over several days as the precipitating illness resolves, then switch to oral maintenance
If diagnosis is not yet established:
- Give dexamethasone 10 mg IV (single dose, does not interfere with cortisol measurement)
- Start IV fluids simultaneously
- Run a Cortrosyn (cosyntropin) stimulation test
- Once test is done, switch to hydrocortisone 100 mg IV q8h until results are known
Mineralocorticoid note: At doses ≥100 mg/day, hydrocortisone provides enough mineralocorticoid activity - fludrocortisone is not needed until the dose drops below 100 mg/day.
Source: Washington Manual of Medical Therapeutics, p.927; Harrison's 22E
3. Septic Shock / Critical Illness-Related Corticosteroid Insufficiency (CIRCI)
- IV hydrocortisone 50-100 mg every 6 hours, OR
- Continuous IV infusion at 10 mg/hour
- Alternative: prednisone 1 mg/kg/day
- Used when septic shock is refractory to fluids and vasopressors
Source: Goodman & Gilman's
4. Sick Day Rules / Stress Dosing (Adults)
Patients on chronic replacement must increase their dose during physiologic stress:
| Situation | Action |
|---|---|
| Minor illness (fever, infection) | Double the usual dose for 2-3 days; resume maintenance when well |
| Vomiting (cannot take PO) | Seek IV/IM glucocorticoid immediately; patients may carry dexamethasone 4 mg IM for self-administration |
| Severe illness or surgery | Hydrocortisone 50 mg IV q8h; taper back to maintenance within 2-3 days after uncomplicated surgery |
Source: Washington Manual of Medical Therapeutics
5. Pediatric Dosing (Harriet Lane Handbook, 23rd ed.)
Chronic replacement (physiologic): ~8-12 mg/m²/day orally in 2-3 divided doses.
Stress dosing in children:
| Stress Level | Dose |
|---|---|
| Moderate (minor illness, fever) | Hydrocortisone 30-50 mg/m²/day PO ÷ TID, OR prednisone 6-10 mg/m²/day PO ÷ BID |
| Severe (surgery, severe illness, shock) | IV bolus 50 mg/m², then 50-100 mg/m²/day as continuous infusion or ÷ Q6h; OR IM 25 mg/m²/dose Q6h |
Rapid approximations for emergency stress dosing:
- Infant: 25 mg hydrocortisone
- Small child: 50 mg hydrocortisone
- Large child/adolescent: 100 mg hydrocortisone
Source: Harriet Lane Handbook, 23rd ed.
6. Congenital Adrenal Hyperplasia (CAH)
- Standard replacement: 10-15 mg/m²/day in 2-3 divided doses
- Modified/delayed-release hydrocortisone (e.g., Chronocort) mimics the physiologic cortisol pattern and can provide effective control at lower total daily doses than immediate-release formulations - a significant advantage for long-term management.
Source: Harrison's 22E
7. Glucocorticoid-Induced Adrenal Insufficiency (Tapering)
If glucocorticoids have been used for >3-4 weeks at supraphysiologic doses:
- Do not stop abruptly - taper gradually toward physiologic doses (e.g., prednisone ~3-5 mg/day or equivalent)
- Check early-morning cortisol once at physiologic doses:
- <150 nmol/L (<5 µg/dL): consistent with HPA suppression - continue taper cautiously
- >300 nmol/L (>10 µg/dL): HPA axis recovery likely
- Indeterminate values: consider cosyntropin stimulation test
- High-risk factors: doses > physiologic for >3-4 weeks, CYP3A4 inhibitors (especially ritonavir), inhaled high-dose steroids >1 year, intra-articular injections
Source: Harrison's Principles of Internal Medicine 22E (2025)
Key Dosing Principles Summary
| Context | Dose |
|---|---|
| Chronic replacement (adult) | 15-25 mg/day PO, split 2/3 AM + 1/3 PM |
| Adrenal crisis | 100 mg IV q8h |
| CIRCI / septic shock | 50-100 mg IV q6h or 10 mg/h infusion |
| Minor illness (sick day) | Double maintenance dose x 2-3 days |
| Perioperative/severe illness | 50 mg IV q8h, taper over 2-3 days |
| Pediatric stress (severe) | 50 mg/m² IV bolus then 50-100 mg/m²/day |
Important: Hydrocortisone is preferred over synthetic glucocorticoids (e.g., dexamethasone, prednisone) for replacement therapy because it has both glucocorticoid and mineralocorticoid activity matching endogenous cortisol. Synthetic agents are preferred for anti-inflammatory use where mineralocorticoid effects are unwanted.
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