Hydrocortisone Dosing for Addison's Disease

Standard Maintenance Regimen

The American College of Endocrinology recommends initiating hydrocortisone 15-25 mg daily divided into 2-3 doses for stable outpatients with Addison's disease, with two-thirds given in the morning upon awakening and one-third in early afternoon, plus fludrocortisone 0.05-0.1 mg once daily 1
The Endocrine Society suggests a total daily dose of 15-25 mg hydrocortisone, with a typical dosing schedule of 10 mg upon awakening and 5 mg in early afternoon 1, 2

The American Heart Association recommends fludrocortisone 0.05-0.1 mg once daily for primary adrenal insufficiency, with titration based on volume status, sodium levels, and renin 1, 2

The European Society of Endocrinology states that plasma ACTH and serum cortisol are not useful for dose adjustment, and monitoring should be done primarily through clinical symptoms, including signs of over-replacement and under-replacement 1, 2
The American College of Endocrinology recommends assessing daily energy patterns, mental concentration, and daytime somnolence to fine-tune hydrocortisone dosing 1

The Endocrine Society suggests doubling the regular oral maintenance dose during febrile illness, minor procedures, or intercurrent illness, and continuing the doubled dose for 24-48 hours after stress resolves 3, 4, 5

The American Academy of Clinical Endocrinologists recommends that all patients have an emergency hydrocortisone injection kit, medical alert bracelet/necklace, and steroid emergency card, and receive education on stress dosing for sick days 1, 2, 3, 6

The European Society of Endocrinology recommends adjusting the hydrocortisone schedule for night shift workers to match their work pattern 1
The American College of Sports Medicine suggests adding 5 mg hydrocortisone before marathon running or prolonged exercise, and increasing salt and fluid intake during hot conditions or intense activity 5

The American College of Endocrinology recommends annual consultation to assess replacement adequacy, self-medication practices during illness, and history of adrenal crises, with normal skin pigmentation and blood pressure indicating adequate replacement 7

The Endocrine Society recommends administering 100 mg of hydrocortisone IM before anesthesia, followed by 100 mg of hydrocortisone IM every 6 hours postoperatively until the patient can eat and drink, then doubling the oral dose for 48+ hours before gradually reducing to the normal dose 8, 9.
During the third trimester of pregnancy, it may be necessary to increase hydrocortisone by 2.5-10 mg daily due to increased free cortisol 8, 9.
The American College of Obstetricians and Gynecologists recommends administering a parenteral bolus of 100 mg of hydrocortisone at the onset of labor, repeating every 6 hours if necessary 8, 9.
Postpartum, the oral dose should be doubled for 24-48 hours after delivery, then gradually reduced 8, 9.
For unfamiliar, intense, or prolonged exercise (such as running a marathon), an additional 5 mg of hydrocortisone should be taken before the event 8.
In hot conditions or intense activity, fluid and salt intake should be increased to replace sweat losses 8.