What is the dose of hydrocortisone (cortisol) for stress dose steroid therapy in patients with acute illness?

From the Guidelines

For stress dose steroid therapy in patients with acute illness, the recommended hydrocortisone dose is 50-100 mg intravenously every 6-8 hours, as indicated by the severity of the illness. The dosing should be individualized based on the severity of illness, with higher doses for severe symptoms or life-threatening consequences, and lower doses for less severe stressors 1.

Key Considerations

• Patients with known adrenal insufficiency or those who have been on chronic steroid therapy should receive stress dose steroids during acute illness to prevent adrenal crisis 1.
• The physiological basis for this therapy is that the normal adrenal gland produces approximately 20 mg of cortisol daily, but during severe stress, production increases to 150-300 mg per day.
• Patients with adrenal insufficiency cannot mount this response, necessitating exogenous steroid supplementation to mimic the body's natural stress response and prevent potentially life-threatening adrenal crisis.

Dosing Recommendations

• For minor stress or procedures, a lower dose of 50-75 mg per day may be sufficient.
• For severe symptoms or life-threatening consequences, a dose of 50-100 mg intravenously every 6-8 hours may be necessary, followed by a taper based on clinical response 1.
• The dosing should be adjusted based on the patient's response to therapy, with the goal of preventing adrenal crisis and minimizing the risk of adverse effects.

Clinical Context

• The management of patients with adrenal insufficiency requires close collaboration with endocrinologists and other healthcare professionals to ensure optimal care 1.
• Patients with adrenal insufficiency should be educated on stress dosing for sick days, use of emergency injectables, and when to seek medical attention for impending adrenal crisis.

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

The dose of hydrocortisone for stress dose steroid therapy in patients with acute illness is 100 mg to 500 mg, and may be repeated at intervals of 2,4, or 6 hours as indicated by the patient's response and clinical condition 2.

From the Research

Dose of Hydrocortisone for Stress Dose Steroid Therapy

The dose of hydrocortisone for stress dose steroid therapy in patients with acute illness varies depending on the specific condition and study.

• A study published in 2008 3 recommends hydrocortisone in a dose of 200 mg/day in four divided doses or as a continuous infusion in a dose of 240 mg/day (10 mg/hr) for ≥ 7 days for septic shock.
• Another study published in 2017 4 defines stress dose steroids as 100 mg IV hydrocortisone every eight hours.
• A study published in 2005 5 used a loading dose of 100 mg and followed by a continuous infusion of 0.18 mg/kg/h for 6 days.
• A study published in 2018 6 compared the clinical outcomes of minimized hydrocortisone dose of 100 mg/day to the currently recommended dose of 200 mg/day in the treatment of septic shock patients.
• A study published in 1999 7 used a loading dose of 100 mg given within 30 mins and followed by a continuous infusion of 0.18 mg/ kg/hr.

Key Findings

• The use of stress-dose steroids in critically ill patients with refractory hypotension does not appear to affect in-hospital mortality 4.
• Stress doses of hydrocortisone resulted in a significant reduction in IL-8 serum, but not in S-100B serum and PMN elastase plasma concentrations in patients with hyperdynamic septic shock 5.
• Minimized daily hydrocortisone dosage of 100 mg could lower the occurrence of hyperglycemia without increasing mortality in septic shock, compared with the currently recommended dosage of 200 mg/day 6.
• Infusion of stress doses of hydrocortisone reduced the time to cessation of vasopressor therapy in human septic shock 7.

Considerations

• The diagnosis of tissue corticosteroid resistance remains problematic 3.
• Adrenal insufficiency in critically ill patients is best made by a delta total serum cortisol of < 9 microg/dL after adrenocorticotrophic hormone (250 microg) administration or a random total cortisol of < 10 microg/dL 3.
• The role of glucocorticoids in the management of patients with community-acquired pneumonia, liver failure, pancreatitis, those undergoing cardiac surgery, and other groups of critically ill patients requires further investigation 3.