Adrenal Insufficiency Management

Introduction to Adrenal Insufficiency

Adrenal insufficiency requires replacement therapy with hydrocortisone, with dosing tailored based on patient weight, condition severity, and timing to match physiologic cortisol rhythms 1

For adults with adrenal insufficiency requiring intramuscular (IM) hydrocortisone, the recommended dosing is 50 mg every 6 hours when intravenous administration is not possible, with initial doses for major surgery/procedures under anesthesia and labor and vaginal delivery being 100 mg IM at induction/onset of labor, respectively 2
For patients with adrenal insufficiency who cannot take oral medication or receive IV hydrocortisone, the recommended dose is 50 mg IM every 6 hours (total 200 mg/24 hours) 2
Alternative dosing for major surgery: 2 mg/kg IM at induction, with maintenance of 2 mg/kg IM every 4 hours, and for minor procedures requiring general anesthesia: 2 mg/kg IM at induction 2

For adults with adrenal insufficiency, total daily hydrocortisone doses typically range from 15-20mg divided throughout the day, according to the American College of Endocrinology, with the recommended administration pattern being 2/3 of the daily dose in the morning and 1/3 in the early afternoon to recreate the diurnal rhythm of cortisol, as suggested by the Endocrine Society 1, 3

For perioperative management in children undergoing major surgery, a dose of 2 mg/kg at induction is recommended by the American Academy of Pediatrics, and for minor procedures requiring general anesthesia in children, hydrocortisone 2 mg/kg IV/IM at induction is recommended by the American Academy of Pediatrics 2
For adults undergoing major surgery, 100 mg IV at induction, followed by continuous infusion of 200 mg/24h, is recommended by the American Society of Anesthesiologists, and for minor procedures, doubling the morning dose pre-operatively is recommended by the American Society of Anesthesiologists 2

In pediatric patients with fluid-refractory, catecholamine-resistant shock with suspected adrenal insufficiency, dosages may range from 1-2 mg/kg/day for stress coverage up to 50 mg/kg/day titrated to reverse shock, as recommended by the Society of Critical Care Medicine 4

IM hydrocortisone provides more reliable absorption than oral dosing during stress, with peak levels occurring approximately 1-2 hours after IM injection and a duration of action of approximately 6-8 hours, and clinical signs of adequate replacement include hemodynamic stability, absence of hypotension, and normal electrolytes 2
All patients on chronic hydrocortisone therapy need education on stress dosing for sick days and emergency situations, and a medical alert bracelet or necklace is recommended for patients on chronic therapy, as recommended by the American College of Clinical Endocrinologists 3