Hydrocortisone Therapy

Indications and Dosage

The American College of Oncology recommends replacement therapy for primary adrenal insufficiency (Addison's disease) at doses of 15-20 mg daily in divided doses to mimic diurnal rhythm 1
For patients with known adrenal insufficiency undergoing major surgery, the recommended stress-dose coverage is 100 mg IV at induction followed by continuous infusion of 200 mg/24h 2, 3
For intermediate surgery, the recommended stress-dose coverage is 100 mg IV at induction with subsequent dose adjustments 3
For minor procedures, the recommended stress-dose coverage is weight-based dosing (2 mg/kg IV/IM in children) 4
The management of septic shock with suspected relative adrenal insufficiency is recommended 5
For immune-related adverse events in patients treated with immune checkpoint inhibitors, hydrocortisone is recommended 1

For pediatric patients, weight-based dosing is recommended: 2 mg/kg IV/IM at induction for surgery 4
For pediatric patients, continuous infusion based on weight is recommended:
Weight Dosage
Up to 10 kg 25 mg/24h [2]
11-20 kg 50 mg/24h [2]
Over 20 kg (prepubertal) 100 mg/24h [7]
Over 20 kg (pubertal) 150 mg/24h [4]
For pregnant patients, labor and vaginal delivery, 100 mg IV at onset of labor, followed by continuous infusion of 200 mg/24h is recommended 3
For pregnant patients, Caesarean section, the same as major surgery protocol is recommended 3

Clinical signs of over-replacement include bruising, thin skin, edema, weight gain, hypertension, hyperglycemia 1
Clinical signs of under-replacement include fatigue, nausea, hypotension, electrolyte abnormalities 1
Patients with primary adrenal insufficiency typically also require mineralocorticoid replacement (fludrocortisone) 1
Patients on chronic glucocorticoid therapy (including inhaled) may have hypothalamic-pituitary-adrenal axis suppression requiring stress-dose coverage during illness or surgery 7