Hydrocortisone Prescription for Adrenal Crisis

Immediate Emergency Treatment

• The American College of Internal Medicine recommends immediate administration of hydrocortisone 100 mg IV bolus, followed by continuous IV infusion of 200 mg over 24 hours, along with rapid IV saline resuscitation for acute adrenal crisis 1
• Do not delay treatment for diagnostic testing—draw blood for cortisol and ACTH levels, then start therapy immediately, as recommended by the Journal of Internal Medicine 1
• This initial bolus saturates 11β-HSD type 2 enzymes to provide mineralocorticoid effect, which is critical since high-dose hydrocortisone is needed to achieve mineralocorticoid activity, according to the Journal of Internal Medicine 1
• Simultaneously begin aggressive fluid resuscitation with 0.9% normal saline—infuse 1 liter over the first hour, as recommended by the Journal of Internal Medicine 1

Continuous Maintenance Phase

• The American Society of Anesthesiologists recommends immediate initiation of continuous IV infusion of hydrocortisone 200 mg over 24 hours after the bolus, which is approximately 8.3 mg/hour 2, 1
• Alternative regimen: hydrocortisone 50 mg IV or IM every 6 hours, as recommended by the American Society of Anesthesiologists and the Journal of Internal Medicine 2, 1
• Continue IV hydrocortisone at 200 mg/24 hours for 24-48 hours or until the patient is stable and able to tolerate oral intake, according to the American Society of Anesthesiologists and the Journal of Internal Medicine 2, 1

Transition to Oral Therapy

• Once the patient can tolerate oral intake and the precipitating illness is controlled, transition to oral hydrocortisone at double the patient's usual maintenance dose for 48 hours, as recommended by the American Society of Anesthesiologists and the Journal of Internal Medicine 2, 1
• If recovery is complicated or the patient had major stress, continue doubled oral doses for up to one week before tapering, according to the American Society of Anesthesiologists and the Journal of Internal Medicine 2, 1

Critical Supportive Measures

• Continue slower IV saline infusion for 24-48 hours after the initial liter to maintain adequate hydration, as recommended by the Journal of Internal Medicine 1
• Identify and treat the precipitating cause, which is often infection, accounting for the majority of adrenal crises, according to the Journal of Internal Medicine 1
• Monitor serum sodium, potassium, glucose, and creatinine—expect hyponatremia, hyperkalemia, and prerenal azotemia, as recommended by the Journal of Internal Medicine 1
• For patients with primary adrenal insufficiency, add fludrocortisone 0.05-0.2 mg daily once oral intake resumes, as they require mineralocorticoid replacement, according to the Journal of Internal Medicine 1

Common Pitfalls to Avoid

• Never use dexamethasone as the primary agent in adrenal crisis—it lacks mineralocorticoid activity and has a prolonged half-life that makes dose adjustment difficult, as stated by medical guidelines 3
• Do not abruptly stop stress-dose steroids—always taper gradually over 48 hours to one week depending on clinical recovery, as recommended by the American Society of Anesthesiologists and the Journal of Internal Medicine 2, 1

Hydrocortisone Dosing in Adrenal Crisis

Adult Management

• Give an immediate 100 mg intravenous (or intramuscular) bolus of hydrocortisone, then start a continuous infusion of 200 mg over the next 24 hours (≈8.3 mg/h). This regimen rapidly restores physiologic cortisol levels and provides mineralocorticoid activity needed in crisis. 4

• If a continuous infusion is not feasible, administer 50 mg hydrocortisone intravenously or intramuscularly every 6 hours (total 200 mg/24 h). This alternative achieves the same daily dose. 4

• Continue the 200 mg/24 h IV hydrocortisone infusion for 24–48 hours, or until the patient is clinically stable and can tolerate oral intake. Duration is guided by hemodynamic stability and resolution of the precipitating stressor. 4

• When oral intake is possible, switch to oral hydrocortisone at twice the patient’s usual maintenance dose for the next 48 hours. This “double‑dose” phase supports recovery from the acute stress. 4

• If recovery is complicated or the patient experienced major stress, maintain the doubled oral dose for up to one week before tapering back to the standard maintenance regimen. Tapering reduces the risk of adrenal insufficiency relapse. 4

• Dexamethasone should not be used as the sole stress‑dose glucocorticoid in primary adrenal insufficiency because it lacks mineralocorticoid activity. If dexamethasone must be used temporarily, aggressive saline resuscitation and rapid transition to hydrocortisone are required. 4

Pediatric Management

• Administer an initial hydrocortisone bolus of 2 mg per kilogram body weight intravenously at the onset of adrenal crisis (or at induction for surgery). This dose rapidly restores cortisol levels in children. [5][6]

• Monitor blood glucose hourly during the acute phase, as children are especially prone to hypoglycemia. Frequent glucose checks help prevent life‑threatening lows. [5][6]

• For ongoing crisis or postoperative care, give hydrocortisone 2 mg/kg intravenously or intramuscularly every 4 hours. This schedule maintains adequate cortisol exposure. [5][6]

• If the child is unstable or septic, a weight‑based continuous hydrocortisone infusion may be used instead of intermittent dosing. Continuous infusion provides smoother cortisol levels. [5][6]

• Once enteral nutrition is established, resume oral hydrocortisone at twice the usual maintenance dose for 48 hours, then taper to the standard dose once stability is achieved. This mirrors adult practice for post‑crisis recovery. [5][6]

• Do not allow a child with adrenal insufficiency to fast for more than 6 hours. Prolonged fasting increases the risk of hypoglycemia and adrenal decompensation. [5][6]

• Continue hourly blood‑glucose monitoring until the child can tolerate oral intake after surgery or acute illness. Ongoing monitoring ensures timely detection of hypoglycemia. [5][6]

• In children who have both diabetes insipidus and adrenal insufficiency, strict fluid‑balance management combined with adequate cortisol replacement is essential to avoid hyponatremia. Cortisol is required for appropriate water excretion in this population. [5][6]