What is the indication for stress dose steroids (corticosteroids)?

From the Guidelines

Stress dose steroids are indicated for patients with adrenal insufficiency during times of physiologic stress, and the recommended regimen is hydrocortisone 100 mg IV initially, followed by a continuous infusion of hydrocortisone at 200 mg/24h-1, until the patient can take double their usual oral glucocorticoid dose by mouth, as recommended by the most recent guidelines 1. The indication for stress dose steroids includes any patient on chronic steroid therapy (typically >5 mg prednisone daily for >2 weeks within the past year) or with known primary or secondary adrenal insufficiency who experiences significant illness, trauma, surgery, or other physiologic stressors. Some key points to consider when administering stress dose steroids include:

• The dose and duration of stress dose steroids should be tailored to the individual patient's needs and the severity of the stressful event.
• Patients should be educated about stress dosing and carry an emergency kit containing injectable hydrocortisone for urgent situations.
• The use of stress dose steroids should be guided by clinical judgment and consultation with an endocrinologist when possible.
• It is essential to recognize and diagnose adrenal crisis, which can be a life-threatening medical emergency, and to provide prompt treatment with stress dose steroids. The most recent guidelines recommend that patients with adrenal insufficiency should receive stress dose steroids during times of physiologic stress, such as surgery or severe illness, to prevent adrenal crisis 1. Additionally, patients with a history of immune-related adverse events, such as those treated with immune checkpoint inhibitor therapy, may also require stress dose steroids to manage adrenal insufficiency 1. However, the specific recommendations for stress dose steroids may vary depending on the individual patient's needs and the severity of the stressful event. Overall, the use of stress dose steroids is a critical component of the management of adrenal insufficiency, and healthcare providers should be aware of the indications and guidelines for their use.

From the FDA Drug Label

In patients on corticosteroid therapy subjected to unusual stress, increased dosage of rapidly acting corticosteroids before, during, and after the stressful situation is indicated. 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.

The indication for stress dose steroids (corticosteroids) is for patients on corticosteroid therapy who are subjected to unusual stress, such as:

• Surgery
• Trauma
• Infection
• Other stressful situations In these situations, an increased dosage of rapidly acting corticosteroids may be necessary to help the body respond to the stress. This is because the patient's adrenal glands may not be able to produce enough cortisol to respond to the stress due to the corticosteroid therapy 2, 3, 4.

From the Research

Indications for Stress Dose Steroids

The indications for stress dose steroids, also known as corticosteroids, are as follows:

• Adrenal insufficiency: Patients with adrenal insufficiency require increased hydrocortisone cover during major stress to avoid a life-threatening adrenal crisis 5
• Septic shock: Stress dose hydrocortisone is recommended for patients with septic shock who require vasopressor support, especially if adrenal insufficiency is present 6, 7, 8, 9
• Acute lung injury or acute respiratory distress syndrome (ALI/ARDS): Stress-dose corticosteroid therapy may be warranted in cases of refractory infection-induced ARDS when impending mortality is likely 9
• Major trauma, surgery, or combat stress: Patients exposed to these stressors may require stress dose steroids to maintain cortisol concentrations in the required range 5

Dosage and Administration

The dosage and administration of stress dose steroids vary depending on the specific condition and patient population:

• Hydrocortisone 200-300 mg/day, administered in divided doses or as a continuous infusion, is the preferred corticosteroid in patients with septic shock 7
• Continuous intravenous hydrocortisone infusion is recommended over intermittent bolus administration in the prevention and treatment of adrenal crisis during major stress 5
• High-dose steroids (100 mg every 8 hours) may reduce rates of recurrence of shock and reduce the need for additional vasopressors in patients with septic shock 8