What is the recommended dosing for stress dose steroids in patients at risk of adrenal insufficiency?

Stress Dose Steroids for Adrenal Insufficiency

For patients at risk of adrenal insufficiency, intravenous hydrocortisone 50-100 mg every 6-8 hours is the recommended stress dose steroid regimen for severe physiologic stress or adrenal crisis. 1, 2

Recommended Dosing by Severity

Mild Stress (Minor illness, low-grade fever)

• Double or triple the maintenance dose of oral glucocorticoids
• Typically hydrocortisone 20-30 mg in the morning and 10-20 mg in the afternoon 1
• Or prednisone 10-20 mg daily 1

Moderate Stress (Moderate illness, procedures under local anesthesia)

• Oral glucocorticoids at 2-3 times maintenance dose
• Hydrocortisone 20-30 mg in morning, 10-20 mg in afternoon 1
• Taper back to maintenance dose over 5-10 days once stress resolves 1

Severe Stress (Major illness, surgery, trauma, sepsis)

• IV hydrocortisone 50-100 mg every 6-8 hours 1, 2
• For emergency situations: immediate 100 mg IV hydrocortisone bolus 1, 2
• Alternative: dexamethasone 4 mg IV if diagnosis is uncertain and stimulation testing will be needed 1
• IV fluid resuscitation with normal saline (10-20 ml/kg; maximum 1,000 ml) 2
• Once stabilized, taper to maintenance dose over 5-7 days 1

Special Considerations

Surgery/Procedures

• Major surgery: 100 mg IV hydrocortisone before induction, followed by 50-100 mg every 6-8 hours for 24-48 hours 1, 2
• Minor procedures: Double oral maintenance dose on day of procedure 1
• Endocrine consultation prior to any surgical procedure for stress-dose planning 1

Continuous vs. Bolus Administration

• Continuous IV hydrocortisone infusion (200 mg/24 hours) preceded by an initial bolus of 50-100 mg may be superior to intermittent bolus administration during major stress 3
• This approach better maintains cortisol concentrations in the range observed during major physiologic stress 3

Weight-Based Dosing (Pediatric/Special Populations)

Weight	Induction Dose	Maintenance Dose
Up to 10 kg	2 mg/kg IV	25 mg/24h
11-20 kg	2 mg/kg IV	50 mg/24h
Over 20 kg (prepubertal)	2 mg/kg IV	100 mg/24h
Over 20 kg (pubertal)	2 mg/kg IV	150 mg/24h
[2]

Transitioning Back to Maintenance Therapy

• Once acute stress resolves, taper stress-dose steroids over 5-7 days (severe stress) or 1-2 days (mild stress) 1
• Resume normal maintenance therapy: hydrocortisone 15-25 mg daily or prednisone 3-5 mg daily 4
• For primary adrenal insufficiency, add mineralocorticoid replacement (fludrocortisone 0.05-0.2 mg daily) once enteral feeding is established 2, 4

Patient Education

• All patients with adrenal insufficiency require education on:
  • Stress dosing during illness
  • Use of emergency injectable steroids
  • When to seek medical attention for impending adrenal crisis
  • Medical alert bracelet/card for adrenal insufficiency 1, 2

Common Pitfalls

1. Delayed recognition of adrenal crisis - Maintain high index of suspicion in at-risk patients with hypotension refractory to fluids and vasopressors 5
2. Inadequate dosing during stress - Underdosing during major stress can lead to adrenal crisis and death 6
3. Failure to start corticosteroids first when planning hormone replacement for multiple deficiencies, as other hormones can accelerate cortisol clearance 1
4. Attempting laboratory confirmation of adrenal insufficiency in patients on high-dose corticosteroids for other conditions 1
5. Failure to provide patient education on stress dosing and emergency management 1, 2

Remember that patients with adrenal insufficiency require prompt and adequate stress-dose steroids during periods of physiologic stress to prevent potentially life-threatening adrenal crisis.