What are the indications for stress steroid supplementation?

Indications for Stress Steroids

Stress steroids should be administered to all glucocorticoid-dependent patients at risk of adrenal crisis during periods of physiological stress, including surgery, trauma, illness, and intensive exercise, as there are no long-term adverse consequences of short-term glucocorticoid administration. 1

Primary Indications for Stress Steroid Supplementation

• Adrenal Insufficiency: Patients with diagnosed primary or secondary adrenal insufficiency require stress steroids during physiological stress 1
• Chronic Glucocorticoid Therapy: Patients on prescribed glucocorticoid therapy (prednisolone ≥5 mg/day in adults or hydrocortisone-equivalent dose of 10-15 mg/m² per day in children) across all routes of administration (oral, inhaled, topical, intranasal, intra-articular) may have hypothalamo-pituitary-adrenal axis suppression 1
• Surgical Procedures: All adrenal insufficient patients undergoing surgery require stress dose steroids, with dosing based on the magnitude of the surgical procedure 1
• Acute Illness: Febrile or gastrointestinal infections account for 30-50% of life-threatening adrenocortical crises and require immediate stress steroid administration 2, 3
• Labor and Delivery: Women with adrenal insufficiency require stress dose supplementation at the onset of labor 1
• Critical Illness: Patients with critical illness-related corticosteroid insufficiency have both insufficient circulating cortisol and impaired cellular use of glucocorticoids 4, 5
• Intensive Endurance Exercise: Patients with adrenal insufficiency participating in intensive endurance exercise (marathons, triathlons) require stress-dose steroids to prevent adrenal crisis and improve performance 6

Dosing Recommendations Based on Stress Severity

Mild to Moderate Stress

• Double or triple the usual maintenance dose of glucocorticoids (typically 30-75 mg/day hydrocortisone in divided doses) for patients with moderate symptoms but stable vital signs 7, 2
• For ambulatory patients with mild symptoms, initiate replacement therapy with hydrocortisone 15-20 mg in divided doses, with a maximum of 30 mg daily total dose 7

Severe Stress/Adrenal Crisis

• Immediate IV hydrocortisone 100 mg bolus followed by continuous infusion of hydrocortisone at 200 mg/24 hours until the patient can take oral medications 1, 2
• For circumstances where IV infusion is impractical, intramuscular administration of hydrocortisone 50 mg every 6 hours is recommended 1
• Aggressive fluid resuscitation with 3-4 L of isotonic saline or 5% dextrose in isotonic saline should be initiated simultaneously 2

Special Populations

• Children: Require bolus of hydrocortisone at induction of anesthesia followed by either continuous infusion or four-hourly IV boluses; they need more frequent blood glucose monitoring due to vulnerability to glycemic fluctuations 1
• Pregnant Women: May require higher maintenance doses during later stages of pregnancy (after 20th week), with stress dose supplementation of hydrocortisone 100 mg at onset of labor 1

Important Considerations and Pitfalls

• Clinical diagnosis should take precedence over laboratory confirmation when adrenal insufficiency is suspected; treatment should not be delayed while waiting for test results 2, 8
• Dexamethasone is not adequate as glucocorticoid treatment in patients with primary adrenal insufficiency as it has no mineralocorticoid activity 1, 9
• When administering steroids to patients with other endocrine deficiencies, start corticosteroids first, as other hormone replacements can accelerate cortisol clearance and precipitate adrenal crisis 2
• All patients started on stress steroids should receive education on stress dosing for illness, emergency steroid injection, and should be advised to obtain a medical alert bracelet 2, 3
• Despite increased awareness of stress dose protocols, patients remain at risk of morbidity and death from acute adrenal failure due to suboptimal adherence to glucocorticoid stress protocols 8, 5

Tapering Recommendations

• Once the patient is stabilized, taper parenteral glucocorticoids over 1-3 days to oral maintenance therapy if the precipitating illness permits 2
• For major surgery or complications, tapering may need to continue for up to a week 1
• Return to the appropriate maintenance dose should occur within 48 hours for most cases 1