Hydrocortisone Regimen for Secondary Adrenal Insufficiency

Introduction to Hydrocortisone Therapy

The American College of Endocrinology recommends hydrocortisone 10 mg in the morning and 5 mg at noon as the preferred regimen for maintenance replacement in secondary adrenal insufficiency, due to its superior physiologic mimicry and safety data 1.

Current guidelines recommend hydrocortisone 15-20 mg daily in divided doses as the standard of care for adrenal insufficiency 2, 3, 4.
The typical maintenance regimen is 10 mg morning, 5 mg afternoon, with optional 5 mg evening dose if needed 4.

Hydrocortisone 10 mg morning + 5 mg noon represents proper maintenance dosing, not stress dosing 1, 4.
The American College of Endocrinology clarifies that "10 mg morning and 5 mg afternoon" is often confused with stress-dose protocols, but this is actually a standard maintenance regimen when used as the total daily dose 1.

Monitor for signs of under-replacement, such as lethargy, nausea, weight loss, postural hypotension 1, 5.
Monitor for signs of over-replacement, such as weight gain, insomnia, peripheral edema, cushingoid features 1.

All patients need education on stress dosing, which involves doubling the usual dose for minor illness 5, 4.
Provide emergency hydrocortisone injection kit for self-administration during severe illness or vomiting 5, 4.
Medical alert bracelet/card is mandatory 5, 4.

The regimen "hydrocortisone 10-5-5 mg" mentioned in perioperative guidelines refers to a baseline maintenance dose, not stress dosing 6, 2.
During stress, this baseline is doubled for 48 hours to 1 week post-surgery 6, 2.
Prednisolone lacks the mineralocorticoid activity that hydrocortisone provides at physiologic doses 4.
While this is less critical in secondary adrenal insufficiency, it represents another reason hydrocortisone is preferred 6, 7.

The Endocrine Society recommends doubling the usual hydrocortisone dose for the duration of a minor to moderate illness, typically 48 hours to one week depending on recovery, to prevent adrenal crisis in patients with adrenal insufficiency 8, 9
During illness, patients should double their usual hydrocortisone dose, for example, from 10 mg to 20 mg, until symptoms resolve 8, 9

The American College of Endocrinology recommends immediate intramuscular or intravenous hydrocortisone 100 mg in cases of adrenal crisis, characterized by severe symptoms such as confusion, severe weakness, or hypotension, or when oral medication cannot be taken due to vomiting 8, 9

All patients with adrenal insufficiency should have an emergency hydrocortisone injection kit at home and a trained family member who can administer it, as the risk of adrenal crisis is significant, with 6-8 cases per 100 patients per year 8, 9
Patients should carry a medical alert bracelet or necklace identifying adrenal insufficiency, a steroid emergency card, and have a home emergency injection kit with 100 mg hydrocortisone for IM/IV use 8, 9, 10

The European Society of Endocrinology advises against waiting to see if symptoms improve before doubling the dose—patients should start immediately when illness begins, as delayed treatment increases the risk of progression to adrenal crisis 9
Patients should never abruptly stop doubled doses, but instead taper back to their maintenance dose over 1-2 days once symptoms have fully resolved to avoid rebound insufficiency 9, 11