Is hydrocortisone (Hydrocort) 10mg every 8 hours (q8h) considered a stress dose of steroids?

From the Guidelines

No, hydrocortisone 10 mg every 8 hours (30 mg total daily dose) is not considered a stress dose of steroids. According to the most recent and highest quality study 1, stress dose steroids typically involve much higher doses of hydrocortisone, usually starting at 50-100 mg intravenously every 6-8 hours for major physiologic stress. The dose of 10 mg every 8 hours is more consistent with physiologic replacement therapy for adrenal insufficiency, which aims to mimic normal cortisol production.

Some key points to consider:

• Stress dosing is used when patients with adrenal insufficiency face significant physical stressors like surgery, trauma, or severe illness, as the body would normally increase cortisol production substantially during these times 1.
• Without adequate cortisol during stress, patients with adrenal insufficiency may develop an adrenal crisis, characterized by hypotension, electrolyte abnormalities, and potentially shock.
• The 10 mg q8h dose would be insufficient to prevent these complications during significant physiologic stress.
• Other studies, such as 1, also support the idea that stress dose steroids require higher doses of hydrocortisone, but the most recent and highest quality study 1 provides the most relevant guidance on this topic.

In terms of management, it is essential to educate patients on stress dosing for sick days, use of emergency injectables, and when to seek medical attention for impending adrenal crisis 1. Endocrine consultation should be part of planning before surgery or high-stress treatments, and patients should be advised to wear a medical alert bracelet or necklace to trigger stress dose corticosteroids by emergency medical personnel. The recommended stress dose of hydrocortisone is 50-100 mg intravenously every 6-8 hours, which is significantly higher than the 10 mg q8h dose in question.

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. The dosage of 10mg every 8 hours (q8h) of hydrocortisone is not explicitly stated in the label as a stress dose.

• The label does mention that dosage requirements are variable and must be individualized on the basis of the disease under treatment and the response of the patient.
• It also states that in situations of stress, it may be necessary to increase the dosage of hydrocortisone for a period of time consistent with the patient's condition 2. However, without explicit information on what constitutes a stress dose, it is unclear if 10mg q8h meets this criteria. Therefore, a conservative clinical decision would be to consult additional resources or expert opinion to determine the appropriate dosage for a stress dose of steroids 2.

From the Research

Definition of Stress Dose of Steroids

A stress dose of steroids refers to a higher dose of glucocorticoids administered to patients with adrenal insufficiency during periods of physical stress, such as illness, trauma, or surgery, to prevent adrenal crisis.

Hydrocortisone Dosing

• The standard maintenance dose of hydrocortisone is 15-25 mg per day, divided into two or three separate doses 3.
• During stressful events, additional glucocorticoid supplementation is recommended 3.
• A dose of 10 mg hydrocortisone every 8 hours (q8h) may be considered a stress dose, but its effectiveness in preventing adrenal crisis is not well established 4.

Effectiveness of Stress Dosing

• One study found that patients with primary adrenal insufficiency did not benefit from an extra dose of hydrocortisone before short-term strenuous exercise 4.
• Another study suggested that a continuous intravenous infusion of 200 mg hydrocortisone over 24 hours, preceded by an initial bolus of 50-100 mg hydrocortisone, may be more effective in maintaining cortisol concentrations during major stress 5.

Clinical Guidelines

• Patients with adrenal insufficiency require individualized treatment plans, and the dose of hydrocortisone may need to be adjusted based on the severity of the stress and the patient's response to treatment 6, 7.
• The optimal dose and duration of stress dosing have not been well established, and further research is needed to determine the most effective treatment strategies 5, 3.