Adrenal Insufficiency Management with Hydrocortisone

Maintenance and Dosage

The standard replacement therapy for chronic adrenal insufficiency is hydrocortisone 15-25 mg daily, divided into 2-3 doses, with the first dose taken immediately upon waking and the last dose at least 6 hours before bedtime, as recommended by the Endocrine Society 1, 2
The typical dosing schedule is 10 mg upon waking, 5 mg at midday, and 2.5-5 mg in the early afternoon, according to the Endocrine Society 1, 2
In children, the dose is 6-10 mg/m² body surface area daily, as recommended by the Pediatric Endocrine Society 1, 2
Patients with primary adrenal insufficiency require fludrocortisone 50-200 µg once daily for mineralocorticoid replacement, as recommended by the Endocrine Society 1, 2

Adrenal crisis requires immediate treatment with hydrocortisone 100 mg IV bolus, followed by 100 mg every 6-8 hours, along with rapid IV isotonic saline at 1 L/hour initially, as recommended by the American College of Emergency Physicians 1, 2
Treatment should never be delayed for diagnostic procedures, according to the American College of Emergency Physicians 1
Administer 3-4 L of 0.9% saline over 24 hours with frequent hemodynamic monitoring, as recommended by the American College of Emergency Physicians 3
Taper to double the oral maintenance dose for 24-48 hours once the patient can eat and drink, then return to normal maintenance, as recommended by the Endocrine Society 1, 2

For major surgery, give hydrocortisone 100 mg IV/IM just before anesthesia, followed by continuous infusion of 200 mg/24h until the patient can take oral medications, as recommended by the American Society of Anesthesiologists 4, 5
Administer 100 mg hydrocortisone IV/IM immediately before anesthesia, according to the American Society of Anesthesiologists 6, 7
Continue 100 mg every 6 hours (or 200 mg/24h continuous infusion) until able to eat and drink, as recommended by the American Society of Anesthesiologists 6, 4, 5
Once oral intake resumes, double the usual oral dose for 48+ hours, then taper to normal maintenance, according to the American Society of Anesthesiologists 6, 7

During labor and delivery, give hydrocortisone 100 mg IM at onset of labor, repeated every 6 hours if necessary, or as continuous IV infusion of 200 mg/24h, as recommended by the American College of Obstetricians and Gynecologists 6, 5, 7
Women may require higher maintenance doses during the third trimester (after 20 weeks), according to the American College of Obstetricians and Gynecologists 5, 7
After delivery, double the oral dose for 24-48 hours, then taper to normal maintenance, as recommended by the American College of Obstetricians and Gynecologists 6, 7

Dexamethasone is inadequate for primary adrenal insufficiency as it lacks mineralocorticoid activity and should never be used as sole therapy, according to the Endocrine Society 4, 5
Even mild gastrointestinal upset can precipitate adrenal crisis, as patients cannot absorb oral medications when they need them most, as warned by the American Gastroenterological Association 6, 7
The frequency of acute adrenal crises is 6-8 per 100 patient-years, with common precipitants being vomiting/diarrhea, infections, surgery, and injuries, according to the Endocrine Society 6, 7
Medication errors and omissions during hospital stays account for 8.6% of adrenal crises, as reported by the American Society of Health-System Pharmacists 8

All patients must wear medical alert identification jewelry, carry a steroid emergency card, and have supplies for self-injection of parenteral hydrocortisone, as recommended by the Endocrine Society 1, 2
Patients require education on doubling or tripling oral doses during minor illnesses with fever, according to the Endocrine Society 1, 2
For vomiting or inability to take oral medications, immediate parenteral hydrocortisone 100 mg IM and emergency medical attention are required, as recommended by the American College of Emergency Physicians 1, 2

Annual assessment should include evaluation of symptoms, weight, blood pressure, and serum electrolytes (sodium, potassium), as recommended by the Endocrine Society 1, 2
Screen for associated autoimmune conditions, particularly thyroid dysfunction, according to the American Thyroid Association 1, 2
Monitor bone mineral density every 3-5 years to assess for complications of glucocorticoid therapy, as recommended by the National Osteoporosis Foundation 1, 2

The Association of Anaesthetists and Society for Endocrinology UK (2020) recommends administering stress‑dose hydrocortisone (100 mg IV at induction followed by a 200 mg/24 h infusion) to patients with diagnosed adrenal insufficiency (primary or secondary) undergoing surgery. 9
The same guideline advises that patients on chronic glucocorticoid therapy equivalent to ≥5 mg prednisolone daily (or ≥20 mg hydrocortisone daily) for ≥1 month also require peri‑operative stress‑dose hydrocortisone. 10

In the absence of adrenal insufficiency or chronic glucocorticoid exposure—e.g., a euthyroid patient on methimazole undergoing total abdominal hysterectomy with bilateral salpingo‑oophorectomy—stress‑dose hydrocortisone is not indicated. [9][10]

Anaesthesia guidelines (2020) note that severe pre‑operative anemia (≈7 g/dL hemoglobin) markedly increases cardiac stress during surgery, prompting the need for cardiovascular optimization (e.g., transfusion, hemodynamic monitoring) before the operative procedure. 9