Who requires stress dosing of steroids (corticosteroids) and when should it be administered, preoperatively or postoperatively?

Stress Dosing Steroids: Who Requires It and When to Administer

Patients with primary adrenal insufficiency require stress dose steroids perioperatively, while those on chronic steroids for rheumatic conditions generally do not need supplemental dosing beyond their usual daily dose. 1

Who Requires Stress Dosing Steroids

Patients Who DO Require Stress Dosing:

• Patients with primary adrenal insufficiency (Addison's disease) require stress dose steroids during surgery and medical procedures according to the degree of stress induced 1
• Patients with secondary adrenal insufficiency due to primary hypothalamic disease need perioperative stress dosing 1
• Patients with immune checkpoint inhibitor-related adrenal insufficiency require stress dosing based on symptom severity 1, 2
• Patients receiving glucocorticoids to treat primary adrenal insufficiency require supplemental doses during the perioperative period 3

Patients Who DO NOT Require Stress Dosing:

• Patients with rheumatic diseases (RA, SpA, AS, PsA, SLE) on chronic steroids (≤16 mg/day prednisone or equivalent) should continue their current daily dose rather than receiving supplemental "stress dosing" 1
• Patients on high-dose chronic steroid therapy can continue their usual dosage without additional stress dosing as long as they maintain their regular regimen 1
• There is insufficient evidence supporting routine stress-dose steroids for patients on maintenance steroid therapy 3, 4

When to Administer Stress Dosing

Preoperative Administration:

• For major surgery with long recovery time: 100 mg hydrocortisone IM just before anesthesia 1
• For major surgery with rapid recovery: 100 mg hydrocortisone IM just before anesthesia 1
• For labor and vaginal birth: 100 mg hydrocortisone IM at onset of labor 1
• For minor surgery and major dental procedures: 100 mg hydrocortisone IM just before anesthesia 1

Postoperative Administration:

• For major surgery with long recovery: Continue 100 mg hydrocortisone IM every 6 hours until able to eat and drink, then double oral dose for 48+ hours, then taper to normal dose 1
• For major surgery with rapid recovery: Continue 100 mg hydrocortisone IM every 6 hours for 24-48 hours, then double oral dose for 24-48 hours, then taper to normal dose 1
• For labor and delivery: Double oral dose for 24-48 hours after delivery, then taper to normal dose 1

Dosing Based on Surgical Stress Level

High Stress Procedures (Major Surgery):

• Hydrocortisone 100 mg IV before anesthesia, then 100 mg IV every 6-8 hours for 24-48 hours 5, 2
• Taper to maintenance dose over 1-2 days after able to take oral medications 1

Moderate Stress Procedures:

• Hydrocortisone 50 mg IV before procedure, then resume normal maintenance dose 5, 2

Low Stress Procedures (Minor Surgery):

• Continue usual daily glucocorticoid dose without supplementation for patients on chronic therapy for rheumatic conditions 1
• For patients with adrenal insufficiency, administer usual morning dose before procedure 1

Special Considerations

• In the event of unexplained and fluid-unresponsive hypotension during surgery, administer 100 mg hydrocortisone IV as adrenal insufficiency should be considered in the differential diagnosis 1
• For patients with severe symptoms of adrenal insufficiency, administer hydrocortisone 50-100 mg IV every 6-8 hours with tapering to maintenance doses over 5-7 days 5, 2
• During pregnancy, increased doses may be required due to physiologic increases in corticosteroid-binding globulin and total serum cortisol 1

Common Pitfalls and Caveats

• Failure to identify patients with primary adrenal insufficiency who require stress dosing can lead to life-threatening adrenal crisis 1
• Unnecessary stress dosing in patients on chronic steroids for rheumatic conditions increases infection risk without hemodynamic benefit 1
• Starting other hormone replacements before corticosteroids can precipitate adrenal crisis as other hormones accelerate cortisol clearance 5
• All patients with adrenal insufficiency need education on stress dosing for sick days, emergency injections, and should wear medical alert identification 1, 5
• Patients with adrenal insufficiency should never abruptly discontinue their steroid medication before surgery 1