Should hydrocortisone (corticosteroid) be started orally with a normal fibrinogen level?

Oral Hydrocortisone Management with Normal Fibrinogen Levels

Oral hydrocortisone should be started at double the usual maintenance dose for 24-48 hours following major stress or surgical procedures, even with normal fibrinogen levels, to prevent adrenal crisis. 1

Rationale for Oral Hydrocortisone Supplementation

Normal fibrinogen levels do not preclude the need for stress-dose glucocorticoid coverage. The decision to start oral hydrocortisone is based on:

1. Patient's adrenal status:

   • Patients with known adrenal insufficiency (primary or secondary)
   • Patients on chronic steroid therapy (prednisolone equivalent ≥5mg for ≥4 weeks) 1

2. Recent stress exposure:

   • Post-surgical recovery phase
   • Following major illness or trauma
   • During acute infection or inflammatory conditions

Dosing Recommendations

For Patients with Adrenal Insufficiency:

• Post-major surgery: Double oral hydrocortisone doses for 48 hours or up to a week following major surgery 1
• Post-minor surgery: Double oral hydrocortisone doses for 24 hours, then return to normal dose 1
• During minor illness: Double or triple the usual daily dose 2

For Patients on Chronic Steroids:

• Post-major surgery: Resume enteral glucocorticoid at double the pre-surgical therapeutic dose for 48 hours if recovery is uncomplicated; continue double oral dose for up to a week if complicated 1
• Post-intermediate surgery: Double regular glucocorticoid dose for 48 hours, then continue usual treatment dose if uncomplicated 1

Transition from IV to Oral Therapy

When transitioning from IV hydrocortisone to oral maintenance therapy:

1. Ensure patient is hemodynamically stable
2. Confirm ability to tolerate oral medications
3. Double the usual maintenance oral dose for 24-48 hours 1
4. Taper to normal maintenance dose over 1-3 days 2

Important Considerations

• Do not delay treatment: In suspected adrenal crisis, treatment should not be delayed by diagnostic procedures 1
• Monitoring: Assess clinical response, vital signs, and electrolytes during transition to oral therapy 2
• Avoid abrupt discontinuation: Always taper glucocorticoids gradually rather than stopping abruptly 3
• Patient education: Ensure patients understand stress dosing protocols and have medical alert identification 2

Common Pitfalls to Avoid

• Underdosing: Inadequate stress dosing can lead to adrenal crisis, which has significant mortality risk 1, 2
• Relying solely on fibrinogen or other laboratory values: Clinical assessment of stress and known adrenal status should guide therapy decisions 2
• Improper formulation: Hydrocortisone tablets and suspension are not bioequivalent; tablets provide more reliable dosing 4
• Failure to adjust dose based on clinical response: Dosage requirements are variable and must be individualized based on disease and patient response 3

By following these guidelines, you can ensure appropriate glucocorticoid coverage during stress while minimizing the risks of both under- and over-replacement.