What is the correct dosage for stress dose corticosteroids (steroids)?

From the Guidelines

The correct dosage for stress dose corticosteroids is typically 50-100 mg of hydrocortisone given intravenously every 6-8 hours for adults experiencing acute stress or undergoing major surgery, as recommended by the most recent and highest quality study 1. For implementation:

• Start with an initial IV bolus of hydrocortisone
• Continue with 50-100 mg IV every 6-8 hours for the duration of the acute stress period
• Taper the dose gradually over 5-7 days as the stress resolves These doses are designed to mimic the body's natural cortisol surge during stress and prevent adrenal crisis in patients with known or suspected adrenal insufficiency. Key considerations include:
• The dosage may need to be adjusted based on the individual patient's response and the severity of the stress
• Patients should be closely monitored for signs of adrenal crisis and the dose should be adjusted accordingly
• After the acute stress period, patients should return to their usual maintenance steroid dose or be tapered off if they don't typically require steroids, as recommended by 1. It's also important to note that the use of hydrocortisone allows for the recreation of the diurnal rhythm of cortisol, and typically 2/3 of the dose is given in the morning and 1/3 in the early afternoon, as mentioned in 1. Additionally, education on stress dosing, emergency injectable, and a medical alert or necklace accessory or system is crucial for patients with adrenal insufficiency, as highlighted in 1.

From the FDA Drug Label

In certain overwhelming, acute, life-threatening situations, administration in dosages exceeding the usual dosages may be justified and may be in multiples of the oral dosages. The initial dose of SOLU-CORTEF Sterile Powder is 100 mg to 500 mg, depending on the specific disease entity being treated This dose may be repeated at intervals of 2,4, or 6 hours as indicated by the patient's response and clinical condition

The correct dosage for stress dose corticosteroids (steroids) is 100 mg to 500 mg of hydrocortisone, which may be repeated at intervals of 2,4, or 6 hours as needed, depending on the patient's response and clinical condition 2.

From the Research

Stress Dose Corticosteroids

The correct dosage for stress dose corticosteroids (steroids) is a topic of ongoing research and debate.

• The dosage of stress dose corticosteroids can vary depending on the individual patient and the specific clinical scenario 3, 4, 5, 6, 7.
• A study published in 2014 found that an oral dose of hydrocortisone 20 mg is supraphysiological for routine maintenance, while stress doses above 50 mg 6-hourly would rarely be necessary in managing acute illness 3.
• Another study published in 2020 found that continuous intravenous infusion of 200 mg hydrocortisone over 24 hours, preceded by an initial bolus of 50-100 mg hydrocortisone, was the most appropriate mode and dose of hydrocortisone administration in patients with adrenal insufficiency exposed to major stress 4.
• A study published in 2017 found that patients who received stress-dose steroids (defined as 100 mg IV hydrocortisone every eight hours) had increased mortality, but this association was no longer significant after controlling for patient factors associated with increased likelihood of receiving stress-dose steroids 5.
• A case report published in 2014 described the perioperative management of a patient with primary adrenal insufficiency who underwent general anesthesia twice, and received stress doses of hydrocortisone on the operative day (100 mg x day(-1) of hydrocortisone for operation 1 or 300 mg x day(-1) of hydrocortisone for operation 2) 6.
• A retrospective observational study published in 2023 found that patients who received hydrocortisone for septic shock had higher lactate and Acute Physiology and Chronic Health Evaluation (APACHE) III scores, and longer vasopressor duration, but no association between receipt of hydrocortisone and hospital mortality was detected after multivariable adjustment 7.

Key Findings

• The dosage of stress dose corticosteroids can vary depending on the individual patient and the specific clinical scenario.
• Continuous intravenous infusion of hydrocortisone may be the most appropriate mode of administration in patients with adrenal insufficiency exposed to major stress.
• The use of stress-dose steroids in critically ill patients with refractory hypotension does not appear to affect in-hospital mortality.
• The clinical outcomes of patients who receive hydrocortisone for septic shock are influenced by various factors, including the severity of illness and the use of vasopressors.