What are the dosing recommendations for stress-dose steroids in various medical conditions, including adrenal insufficiency (Addison's disease) and critical illness?

From the Guidelines

Stress dose steroids are essential for patients with adrenal insufficiency during periods of physiological stress, and the recommended dosing regimen is based on the severity of the stress and the patient's individual needs, as outlined in the guidelines from the Association of Anaesthetists, the Royal College of Physicians, and the Society for Endocrinology UK 1.

Key Recommendations

• For minor stress, such as mild illness or low-grade fever, patients should double or triple their usual daily glucocorticoid dose (typically 15-25 mg hydrocortisone) for 2-3 days.
• For moderate stress, like non-critical illness or minor surgical procedures, hydrocortisone 50-75 mg/day divided into 2-3 doses is recommended for 1-2 days.
• Severe stress situations, including major surgery, trauma, or critical illness, require hydrocortisone 100-150 mg/day, typically as 50 mg IV every 6-8 hours, tapering to maintenance doses as the patient improves.
• For patients undergoing surgery, administer 100 mg hydrocortisone IV immediately before anesthesia, followed by 50 mg every 8 hours for 24 hours, then taper over 1-2 days for minor procedures or 2-3 days for major procedures.
• Patients with suspected adrenal crisis should receive immediate hydrocortisone 100 mg IV bolus followed by continuous infusion or divided doses.

Education and Collaboration

• Patients should be educated to carry emergency hydrocortisone and wear medical alert identification to ensure proper management during unexpected stressful situations.
• Collaboration with the patient's endocrinologist is essential when planning scheduled surgery and caring for postoperative cases, especially for patients with multiple risk factors.

Additional Considerations

• The use of corticosteroids for other immune-related adverse events can cause isolated central adrenal insufficiency with a low ACTH.
• Laboratory confirmation of adrenal insufficiency should not be attempted in patients given high-dose corticosteroids for other immune-related adverse events until treatment is ready to be discontinued.
• Consider consulting endocrinology for recovery and weaning protocols using hydrocortisone in patients with symptoms of adrenal insufficiency after weaning off corticosteroids.

From the FDA Drug Label

5 mg may suffice, while in severe diseases doses higher than 9 mg may be required. During stress it may be necessary to increase dosage temporarily. Administration of high dose corticosteroid therapy should be continued only until the patient’s condition has stabilized and usually not longer than 48 to 72 hours. Dexamethasone sodium phosphate injection is generally administered initially in a dosage of 10 mg intravenously followed by four mg every six hours intramuscularly until the symptoms of cerebral edema subside.

The dosing recommendations for stress-dose steroids in various medical conditions, including adrenal insufficiency (Addison's disease) and critical illness, are as follows:

• Initial dosage: 5 mg may be sufficient, but higher doses (up to 9 mg or more) may be required in severe diseases.
• Stress doses: May need to be increased temporarily during stress.
• High-dose therapy: Should be continued only until the patient's condition has stabilized, usually not longer than 48 to 72 hours.
• Cerebral edema: Initial dosage of 10 mg intravenously, followed by 4 mg every 6 hours intramuscularly. Key considerations include:
• Dosage adjustment: Should be based on the patient's response and clinical status.
• Duration of therapy: Should be as short as possible to minimize adverse reactions. 2

From the Research

Dosing Recommendations for Stress-Dose Steroids

• The dosing recommendations for stress-dose steroids in various medical conditions, including adrenal insufficiency (Addison's disease) and critical illness, vary depending on the specific condition and the level of stress involved 3, 4, 5, 6, 7.
• For patients with adrenal insufficiency, the recommended dose of hydrocortisone is 200 mg over 24 hours, preceded by an initial bolus of 50-100 mg, administered via continuous intravenous infusion 3.
• In cases of major stress, such as surgery or sepsis, the dose of hydrocortisone may need to be increased to 100 mg or more, depending on the severity of the stress 4, 6.
• For patients with primary adrenal insufficiency participating in intensive endurance exercise, a "stress-dose" of adrenal replacement therapy may be necessary to prevent adrenal crisis and improve performance 5.
• The administration of stress-dose glucocorticoids during the perioperative period is recommended for patients with adrenal insufficiency or those who have been taking glucocorticoids for an extended period 6, 7.

Specific Conditions and Dosing Recommendations

• Adrenal insufficiency (Addison's disease): 200 mg hydrocortisone over 24 hours, preceded by an initial bolus of 50-100 mg, administered via continuous intravenous infusion 3.
• Critical illness: 100 mg or more of hydrocortisone, depending on the severity of the stress 4, 6.
• Intensive endurance exercise: a "stress-dose" of adrenal replacement therapy, exact dose not specified 5.
• Perioperative period: stress-dose glucocorticoids, exact dose not specified, but recommended to be equivalent to about 100 mg of cortisol for major surgery 6, 7.

Administration Modes and Monitoring

• Continuous intravenous infusion is the recommended administration mode for hydrocortisone in patients with adrenal insufficiency exposed to major stress 3.
• Monitoring of serum cortisol and cortisone levels, as well as urinary glucocorticoid metabolite excretion, may be necessary to determine the effectiveness of stress-dose steroid therapy 3, 4.