What are the indications for administering stress dose steroids (corticosteroids)?

From the Guidelines

Stress dose steroids should be administered when a patient with adrenal insufficiency faces physiological stress such as surgery, trauma, or severe illness, with the recommended dose being hydrocortisone 100 mg IV immediately, followed by a continuous infusion of 200 mg/24h, as stated in the guidelines from the Association of Anaesthetists, the Royal College of Physicians, and the Society for Endocrinology UK 1. For adults, this regimen is preferred above others due to enhanced safety, and it should be tapered back to the appropriate maintenance dose, in most cases within 48 hours, although for up to a week if surgery is more major or complicated - clinical judgement should be used to guide this 1. Intramuscular administration may be prescribed in circumstances where intravenous infusion therapy is impractical, and children with adrenal insufficiency can be treated with a bolus of hydrocortisone at induction of anaesthesia followed by an immediate continuous infusion of hydrocortisone, or alternatively with a bolus at induction followed by subsequent four-hourly intravenous boluses of hydrocortisone in the postoperative period 1. Some key points to consider include:

• The importance of collaborating with the patient's endocrinologist when planning scheduled surgery and when caring for postoperative patients, especially for patients with multiple risk factors (age, comorbidities) 1.
• The need for patients to receive education on stress dosing for sick days, use of emergency injectables, and when to seek medical attention for impending adrenal crisis, as well as the importance of carrying a medical alert bracelet or necklace for adrenal insufficiency to trigger stress-dose corticosteroids by emergency medical personnel 1.
• The potential for corticosteroid use to cause isolated central adrenal insufficiency, and the need for laboratory confirmation of adrenal insufficiency to be done with caution in patients on corticosteroids for other conditions 1.
• The recommendation to start corticosteroids first when planning hormone replacement therapy for multiple deficiencies, and to be aware of the need to start corticosteroids first when planning hormone replacement therapy for multiple deficiencies 1.

From the FDA Drug Label

In patients on corticosteroid therapy subjected to any unusual stress, increased dosage of rapidly acting corticosteroids before, during, and after the stressful situation is indicated If the patient is receiving steroids already, dosage may have to be increased. Since mineralocorticoid secretion may be impaired, salt and/or a mineralocorticoid should be administered concurrently.

The patient likely requires an increased dose of dexamethasone due to the stressful situation, and the dosage may need to be adjusted based on the patient's current steroid regimen. Additionally, salt and/or a mineralocorticoid should be administered concurrently to address potential mineralocorticoid secretion impairment 2.

From the Research

Administration of Stress Dose Steroids

• The administration of stress dose steroids is a critical aspect of managing adrenal insufficiency, as it helps to prevent adrenal crisis, a life-threatening emergency 3.
• The exact dose of stress dose steroids may vary, but studies suggest that a daily glucocorticoid replacement dose of 15 to 25 mg with a midpoint of 20 mg of hydrocortisone is recommended in otherwise healthy individuals with adrenal insufficiency 4.

Types of Steroids Used

• Hydrocortisone and prednisolone are two common types of steroids used for glucocorticoid replacement therapy in adrenal insufficiency 5.
• Prednisolone has been recommended due to its longer duration of action and lower cost, but studies have shown that mortality rates may be higher with prednisolone compared to hydrocortisone in primary adrenal insufficiency 5.

Optimization of Steroid Replacement Therapy

• The goal of steroid replacement therapy is to mimic the natural cortisol circadian rhythm, which can be challenging with traditional twice- or thrice-daily hydrocortisone regimens 6.
• Prednisolone day curves can be used to accurately downtitrate patients to the minimum effective dose, and target ranges for prednisolone have been established at different time points after administration 6.
• Low-dose prednisolone of 2-4 mg is safe and effective in most patients with adrenal insufficiency, and doses can be titrated with either 4-, 6-, or 8-h single time point drug levels 6.

Management of Adrenal Insufficiency

• Adrenal insufficiency is a life-threatening condition that requires life-long glucocorticoid substitution therapy, as well as stress adaptation to prevent adrenal crises 7.
• The European Reference Networks on rare endocrine conditions aim to harmonize treatment and ensure access to specialized patient care for individual case-by-case treatment decisions 7.
• Optimizing prednisolone or prednisone replacement in adrenal insufficiency is crucial to improve patient outcomes and reduce mortality rates 6.