What is the recommended dosage for stress dose steroids, such as hydrocortisone (corticosteroid), methylprednisolone (corticosteroid), or dexamethasone (corticosteroid)?

Stress Dose Steroids Recommendations

For patients requiring stress dose steroids, administer hydrocortisone 50-100 mg intravenously every 6-8 hours for severe symptoms, with tapering to maintenance doses over 5-7 days. 1

Dosing Based on Severity

Mild Symptoms (Grade 1)

• Initiate replacement therapy with hydrocortisone 15-20 mg in divided doses (typically 2/3 in morning, 1/3 in early afternoon) 1
• Titrate hydrocortisone to maximum of 30 mg daily total dose for residual symptoms of adrenal insufficiency 1
• For patients with primary adrenal insufficiency, add fludrocortisone 0.05-0.1 mg/day 1

Moderate Symptoms (Grade 2)

• Initiate outpatient corticosteroid treatment at 2-3 times maintenance dose (hydrocortisone 30-50 mg total daily dose or prednisone 20 mg daily) 1
• Decrease stress dose corticosteroids down to maintenance doses after 2 days 1
• Consider clinic evaluation to assess need for hydration and supportive care 1

Severe Symptoms/Adrenal Crisis (Grade 3-4)

• Administer IV hydrocortisone 50-100 mg every 6-8 hours initially 1, 2
• Provide rapid volume resuscitation with at least 2L of normal saline 1, 2
• Taper stress dose corticosteroids down to oral maintenance doses over 5-7 days 1, 3
• Never delay treatment of suspected adrenal crisis for diagnostic procedures 2

Steroid Equivalencies and Alternatives

• Hydrocortisone 20 mg is equivalent to prednisone 5 mg 1
• For high-dose therapy, methylprednisolone can be administered at 30 mg/kg intravenously over at least 30 minutes, repeated every 4-6 hours for 48 hours 4
• Dexamethasone can be used initially if cortisol testing is needed (as it doesn't interfere with cortisol assays) 5

Duration of Stress Dose Treatment

• High-dose corticosteroid therapy should generally be continued only until the patient's condition has stabilized, usually not beyond 48-72 hours 4, 6
• After initial stabilization, transition to oral hydrocortisone at double the usual maintenance dose 2
• Continue doubled oral dose for 48 hours to 1 week, depending on clinical recovery 2, 3

Special Considerations

• All patients need education on stress dosing for sick days, use of emergency injectables, and medical alert identification 1, 2
• During physiological stress, cortisol requirements increase up to five-fold (approximately 100 mg/day) compared to normal daily production of 20 mg 2
• Patients with comorbidities such as asthma and diabetes are more vulnerable to adrenal crisis 2
• Ensure mineralocorticoid replacement with fludrocortisone (0.05-0.2 mg daily) is restarted when hydrocortisone dose falls below 50 mg/day for patients with primary adrenal insufficiency 2

Monitoring and Follow-up

• Assess blood pressure, heart rate, and clinical symptoms frequently during initial resuscitation 2
• Be alert to increased vasopressor requirements during steroid tapering, which may occur in up to 37.4% of patients at 24 hours after initiating taper 3
• Consider endocrine consultation for recovery and weaning protocols in patients with symptoms of adrenal insufficiency after weaning off corticosteroids 1

Pitfalls and Caveats

• Starting other hormone replacements before corticosteroids can precipitate adrenal crisis, as other hormones accelerate cortisol clearance 1
• Adrenal crisis symptoms can occur in physiologically stressed patients while plasma cortisol levels are normal or even high (relative adrenal insufficiency) 2
• Mortality risk is significantly higher in patients with untreated adrenal insufficiency 2
• Rapid administration of large IV doses of methylprednisolone (>0.5g over <10 minutes) may cause cardiac arrhythmias 4