Stress Dose Steroids Recommendations
For patients requiring stress-based steroid therapy, the recommended dosage is 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
Severe Symptoms
- For patients with severe symptoms or hemodynamically significant adrenal insufficiency, administer hydrocortisone 50-100 mg intravenously every 6-8 hours 2, 1
- Taper stress dose corticosteroids down to oral maintenance doses over 5-7 days 2
- For septic shock, hydrocortisone 200 mg/day in four divided doses or as a continuous infusion of 240 mg/day (10 mg/hr) for ≥7 days is recommended 2
Moderate Symptoms
- Consider oral pulse dose therapy with prednisone 1 mg/kg/day (or equivalent) in patients with moderate symptoms 2
- Taper over 1-2 weeks and transition to physiologic maintenance therapy once down to 5 mg prednisone equivalent 2
Mild Symptoms/Maintenance Therapy
- For mild symptoms or maintenance therapy, initiate hydrocortisone 15-20 mg in divided doses 1
- Maximum of 30 mg daily total dose for residual symptoms of adrenal insufficiency 1
- For primary adrenal insufficiency, add fludrocortisone 0.05-0.1 mg/day 1
Administration Methods
Continuous vs. Bolus Administration
- Continuous intravenous hydrocortisone infusion is the only administration mode that persistently achieves median cortisol concentrations in the range observed during major stress 3
- For major stress, continuous intravenous infusion of 200 mg hydrocortisone over 24 hours, preceded by an initial bolus of 50-100 mg hydrocortisone, is optimal 3
- For septic shock, hydrocortisone can be administered either as four divided doses or as a continuous infusion 2
Special Considerations
Chronic Steroid Users
- Patients on chronic steroids (≤20 mg/day prednisone or equivalent) should continue their usual daily dose rather than receiving supra-physiologic "stress dosing" during acute illness 4
- No evidence supports routine "push-dose steroids" as long as patients on high-dose chronic steroid therapy continue to assume their usual dosage 2
Perioperative Management
- In the event of hypotension related to adrenal crisis in the perioperative period, administer a push dose of 100 mg hydrocortisone, followed by 50 mg hydrocortisone every 6 hours 2
- For patients with documented or presumed hypothalamic-pituitary-adrenal axis suppression, perioperative stress-dose steroid administration may still be utilized despite the absence of high-quality evidence 2
Patient Education and Follow-up
- All patients need education on stress dosing for sick days, use of emergency steroid injectables, and medical alert identification 2, 1
- During physiological stress, cortisol requirements increase up to five-fold (approximately 100 mg/day) compared to normal daily production of 20 mg 1
- Consider endocrine consultation for recovery and weaning protocols in patients with symptoms of adrenal insufficiency after weaning off corticosteroids 1
Important Pitfalls and Caveats
- Starting other hormone replacements before corticosteroids can precipitate adrenal crisis, as other hormones accelerate cortisol clearance 2, 1
- Adrenal crisis symptoms can occur in physiologically stressed patients while plasma cortisol levels are normal or even high (relative adrenal insufficiency) 1
- Mortality risk is significantly higher in patients with untreated adrenal insufficiency 1
- Steroid therapy is associated with increased morbidity and mortality among surgical patients, with complications including anastomotic leak or dehiscence 2
- Unnecessarily increasing steroid dose can increase infection risk in patients already at risk due to other conditions 4