What is the recommended stress dosing regimen for patients with Addison's disease (adrenal insufficiency) during periods of significant stress?

Stress Dosing in Addison's Disease

For patients with Addison's disease experiencing major stress (surgery, severe illness, trauma), administer hydrocortisone 100 mg IV bolus immediately, followed by continuous IV infusion of 200 mg over 24 hours until the patient can tolerate oral medications, then taper to maintenance doses over 48 hours to 7 days depending on stress severity. 1, 2

Dosing by Stress Severity

Severe Stress or Adrenal Crisis

• Immediate IV hydrocortisone 100 mg bolus at induction of anesthesia or onset of crisis 1, 2
• Follow with continuous IV infusion of hydrocortisone 200 mg over 24 hours until oral intake is possible 1, 2, 3
• If IV infusion is impractical, give hydrocortisone 50 mg IM every 6 hours as an alternative 1, 2
• For established adrenal crisis with severe symptoms, hydrocortisone 50-100 mg IV every 6-8 hours is appropriate 1, 4
• Taper stress doses down to oral maintenance over 5-7 days for uncomplicated cases 1, 4
• For major surgery or complications, tapering may extend up to one week 1, 2

Moderate Stress (Minor Surgery, Moderate Illness)

• Double or triple the usual maintenance dose, typically 30-75 mg/day hydrocortisone in divided doses 2, 4
• Continue elevated dosing until the stressor resolves 2

Mild Stress (Minor Illness, Dental Procedures)

• Increase maintenance hydrocortisone to 30 mg daily total dose in divided doses 2, 4
• Return to baseline once symptoms resolve 2

Critical Timing and Administration Principles

Continuous IV infusion is superior to intermittent bolus dosing because it is the only administration mode that persistently maintains median cortisol concentrations in the physiologic stress range 3. The pharmacokinetic modeling demonstrates that a 50-100 mg initial bolus followed by 200 mg/24 hours continuous infusion best mimics the cortisol response to major stress 3.

If you are uncertain whether stress dosing is needed, give it anyway—there are no long-term adverse consequences of short-term glucocorticoid administration, but withholding can be fatal 1, 2.

Special Populations

Obstetric Patients

• Women may require higher maintenance doses from the 20th week of pregnancy onward 1
• At onset of labor, give hydrocortisone 100 mg IV bolus 1, 2
• Follow with either continuous IV infusion of 200 mg/24 hours or 50 mg IM every 6 hours until after delivery 1

Pediatric Patients

• Children require bolus hydrocortisone at induction of anesthesia followed by either continuous infusion or four-hourly IV boluses 1, 2
• Monitor blood glucose more frequently in children as they are more vulnerable to glycemic fluctuations 1, 2
• Minimize fasting periods and prioritize these patients on surgical lists 1

Critical Pitfalls to Avoid

Never use dexamethasone alone in primary adrenal insufficiency—it lacks mineralocorticoid activity and will not prevent crisis 1, 2.

Always start corticosteroids first when replacing multiple hormone deficiencies, as other hormones (particularly thyroid hormone) accelerate cortisol clearance and can precipitate adrenal crisis 1, 4.

Do not delay treatment to obtain laboratory confirmation—clinical diagnosis takes precedence, and treatment should begin immediately when adrenal crisis is suspected 2. The mortality rate is 0.5 per 100 patient-years if untreated 4, 5.

Ensure adequate volume repletion with at least 2 liters of normal saline in severe cases, as aldosterone deficiency causes profound volume depletion 1.

Patient Education Requirements

All patients with Addison's disease must receive education on:

• Stress dosing protocols for sick days 1, 2, 4
• Use of emergency injectable steroids 1, 2, 4
• When to seek immediate medical attention for impending crisis 1, 2
• Medical alert bracelet identification to trigger stress-dose corticosteroids by emergency medical services 1, 2

The emergency card warning about acute glucocorticoid replacement has high value in reducing morbidity and mortality 5.

Maintenance Therapy Considerations

Once stabilized, taper parenteral glucocorticoids over 1-3 days to oral maintenance if the precipitating illness permits 2. For most cases, return to appropriate maintenance doses within 48 hours 1, 2.

Standard maintenance dosing is hydrocortisone 15-20 mg daily in divided doses (typically 10 mg morning, 5 mg afternoon, 5 mg evening to mimic diurnal variation) 4, 6. Add fludrocortisone 0.05-0.1 mg daily for mineralocorticoid replacement in primary adrenal insufficiency 4, 6.