What is the recommended regimen for stress dose steroids in patients?

From the Guidelines

The recommended regimen for stress dose steroids in patients with adrenal insufficiency during periods of stress typically involves hydrocortisone administration, with dosing dependent on the level of stress, ranging from 2-3 times the usual daily dose for minor stress to intravenous hydrocortisone 50-100 mg Q 6-8 hours for major stress. For minor stress such as mild illness with fever, patients should take 2-3 times their usual daily dose of hydrocortisone, divided into three doses per day 1. For moderate stress like non-critical illness or minor surgical procedures, hydrocortisone 30-50 mg total dose or prednisone 20 mg daily is appropriate, with the dose decreased to maintenance levels after 2 days 1. For major stress including critical illness, trauma, or major surgery, intravenous hydrocortisone 50-100 mg Q 6-8 hours is given initially, with tapering down to oral maintenance doses over 5-7 days 1. This regimen should continue throughout the period of stress and then be tapered back to maintenance doses as the patient improves. Stress dosing is necessary because the normal physiologic response to stress involves increased cortisol production, which patients with adrenal insufficiency cannot achieve on their own. Without adequate cortisol during stress, these patients risk adrenal crisis, which can be life-threatening with symptoms including hypotension, shock, electrolyte abnormalities, and altered mental status.

Key considerations in stress dose steroid administration include:

• The use of hydrocortisone to recreate the diurnal rhythm of cortisol, with 2/3 of the dose given in the morning and 1/3 in the early afternoon 1
• The potential need for fludrocortisone in patients with primary adrenal insufficiency, with dosing adjusted based on volume status, sodium level, and renin response 1
• The importance of patient education on stress dosing, emergency injectables, and when to seek medical attention for impending adrenal crisis 1
• The need for endocrine consultation in planning for surgery or high-stress treatments, and for patients with adrenal insufficiency who are taking medications that induce CYP3A4 or are obese 1.

Overall, the goal of stress dose steroid administration is to mimic the normal physiologic response to stress and prevent adrenal crisis, while minimizing the risks of over-replacement and iatrogenic Cushing's syndrome.

From the FDA Drug Label

Increased dosage of rapidly acting corticosteroids is indicated in patients on corticosteroid therapy who are subjected to any unusual stress before, during, and after the stressful situation The recommended regimen for stress dose steroids in patients is to increase the dosage of rapidly acting corticosteroids in patients on corticosteroid therapy who are subjected to any unusual stress before, during, and after the stressful situation 2.

• Key points:
  • Increase dosage of rapidly acting corticosteroids
  • For patients on corticosteroid therapy
  • Subjected to unusual stress
  • Before, during, and after the stressful situation However, the exact dosage is not specified in the provided drug labels.

From the Research

Stress Dose Steroids Regimen

The recommended regimen for stress dose steroids in patients varies depending on the specific condition and severity of the stress.

• For patients with adrenal insufficiency, a continuous intravenous infusion of 200 mg hydrocortisone over 24 hours, preceded by an initial bolus of 50-100 mg hydrocortisone, is recommended to maintain cortisol concentrations in the required range 3.
• In critically ill patients with refractory hypotension, stress-dose steroids (100 mg IV hydrocortisone every eight hours) may be considered, although its effect on in-hospital mortality is unclear 4.
• For patients with septic shock, hydrocortisone 200-300 mg/day, administered in divided doses or as a continuous infusion, is the preferred corticosteroid and should be started as early as possible 5.

Administration Routes

Different administration routes for stress dose steroids have been studied, including:

• Rectal hydrocortisone, which can be a safe alternative to parenteral administration in patients with adrenal insufficiency, but its use is recommended only after previously documenting an adequate serum cortisol concentration three hours after receiving a test dose 6.
• Intravenous bolus administration, which may be effective in preventing posttraumatic stress disorder (PTSD) when administered within 6 hours of the traumatic event, particularly during nocturnal hours when cortisol levels are low 7.

Patient Characteristics

Patient characteristics associated with an increased likelihood of receiving stress-dose steroids include:

• Age >65
• Diabetes mellitus
• Congestive heart failure
• Burn injuries
• Injury Severity Score >15
• Lower blood pressure
• Higher heart rate 4