Determine hydrocortisone replacement dosing regimen
STEP 1 — Gather Information
Confirm diagnosis of adrenal insufficiency requiring glucocorticoid replacement; assess patient preference for dosing frequency; consider any contraindications to divided dosing (e.g., adherence issues, schedule constraints).
STEP 2 — Rule In / Rule Out
Determine if the patient can adhere to divided dosing (two or three times daily) versus prefers a single daily dose regimen.
STEP 3 — Classify or Stratify
If divided dosing is preferred, choose between a two-dose regimen (morning + afternoon) or three-dose regimen (morning + lunch + late afternoon) based on lifestyle; if single dose is preferred, prepare to administer the total daily dose once daily.
STEP 4 — Decide
Prescribe hydrocortisone 15–20 mg total daily according to the selected regimen; provide clear instructions on timing and stress-dose adjustments for illness or surgery.
Clinical Guardrails / Mimics / Pitfalls
Avoid over-replacement (>20 mg/day) unless clinically indicated for stress; avoid under-replacement (<15 mg/day) unless adverse effects occur; do not use fludrocortisone in secondary adrenal insufficiency; avoid dexamethasone for routine replacement; monitor for Cushingoid features, weight gain, or signs of adrenal crisis.
Concrete Clinical Example
A 48-year-old man with new-onset secondary adrenal insufficiency prefers twice-daily dosing; prescribe HC 10 mg upon awakening and 5 mg in the afternoon; counsel on stress dosing (double or triple dose) during febrile illness.
Source: Hormonal Replacement in Hypopituitarism in Adults: An Endocrine Society Clinical Practice Guideline, Endocrine Society, 2016, doi:10.1210/jc.2016-2118