Should a stress dose of steroids be given to a patient on chronic prednisone (corticosteroid) 20mg daily admitted with community-acquired pneumonia (CAP), and if so, what dose?

Stress Dose Steroids for Patients on Chronic Prednisone with Community-Acquired Pneumonia

For a patient on chronic prednisone 20mg daily who is being admitted with community-acquired pneumonia, you should continue their usual daily dose of prednisone rather than administering stress-dose steroids. 1

Rationale for Continuing Current Dose

• Patients receiving chronic glucocorticoids (≤20 mg/day prednisone or equivalent) should continue their usual daily dose rather than receiving supra-physiologic "stress dosing" during acute illness 1
• The Centers for Disease Control and Prevention considers 20 mg/day of prednisone for at least 2 weeks as the cutoff for immunosuppression, which your patient is at but not exceeding 1
• Low-quality randomized controlled trial evidence and observational studies suggest no significant hemodynamic difference between patients given their current daily glucocorticoid dose compared to those receiving stress-dose steroids 1

Special Considerations for CAP

• For patients with severe CAP who are hypotensive and fluid-resuscitated, screening for occult adrenal insufficiency may be appropriate, but this is different from routine stress dosing 1
• Corticosteroid therapy for CAP itself (separate from chronic steroid management) remains controversial, with some evidence suggesting potential benefits in severe cases, but this is distinct from stress dosing for patients already on steroids 1, 2

Clinical Algorithm for Management

1. Continue the patient's usual 20mg daily prednisone dose 1
2. Monitor for signs of hemodynamic instability:
   • If the patient develops hypotension despite fluid resuscitation, consider screening for adrenal insufficiency 1
   • If adrenal insufficiency is suspected, only then consider hydrocortisone 50-100mg IV every 6-8 hours 3
3. Watch for clinical deterioration:
   • If the patient shows signs of septic shock, consider additional corticosteroid therapy as part of sepsis management, not as stress dosing 1

Pitfalls to Avoid

• Unnecessarily increasing steroid dose can increase infection risk in patients already at risk due to pneumonia 1
• Administering stress-dose steroids when not indicated may prolong exposure to higher steroid doses and increase risk of adverse effects 4
• Confusing recommendations for stress dosing in surgical settings with those for acute medical illness 1

Monitoring

• Monitor for signs of adrenal insufficiency (fatigue, weakness, dizziness, nausea, hypotension) 3, 5
• Watch for hyperglycemia, which is the most common adverse effect of corticosteroid therapy in CAP 6, 7
• Assess for improvement in respiratory status and clinical stability, as these are important markers of treatment success 7, 2

Remember that while recent evidence suggests corticosteroids may benefit patients with severe CAP 2, this is separate from the question of stress dosing in patients already on chronic steroids. The recommendation is to continue the usual 20mg daily dose rather than increasing to stress-dose levels.