What is the stress dose for corticosteroids (steroids)?

Stress Dose Steroids

For patients with adrenal insufficiency experiencing major physiological stress (surgery, sepsis, trauma), administer hydrocortisone 100 mg IV bolus immediately, followed by continuous IV infusion of 200 mg over 24 hours. 1, 2, 3, 4

Initial Dosing for Major Stress

• Give hydrocortisone 50-100 mg IV bolus at the onset of major stress (surgery induction, sepsis, trauma, active labor), followed immediately by continuous infusion 1, 4
• Continuous IV infusion of 200 mg hydrocortisone over 24 hours is superior to intermittent bolus dosing for maintaining cortisol levels in the physiologic stress range 4
• Alternatively, if continuous infusion is unavailable, give hydrocortisone 50 mg IV/IM every 6 hours 1

Context: Why This Dose?

• During major physiological stress, cortisol requirements increase up to five-fold (approximately 100 mg/day) compared to normal daily production of 20 mg 2, 3
• Adrenal crisis can occur even when plasma cortisol levels appear normal or elevated (relative adrenal insufficiency), making empiric dosing critical 1, 3
• Continuous infusion was the only administration mode in pharmacokinetic studies that persistently achieved median cortisol concentrations matching those observed during major stress 4

Tapering After Stabilization

• Once hemodynamically stable and tolerating oral intake, switch to oral hydrocortisone at double the usual maintenance dose (e.g., if usual dose is 10-5-5 mg, give 20-10-10 mg) 1, 3
• Continue doubled oral dose for 48 hours after minor/moderate stress, or up to 1 week following major surgery 1, 3
• Taper stress-dose IV steroids down to oral maintenance doses over 5-7 days 1, 2
• If patient remains critically ill or unstable, continue IV infusion until recovery 1, 3

Mild to Moderate Stress (Sick Days)

• For febrile illness, minor procedures, or intercurrent illness: double the regular oral maintenance dose 1
• Standard maintenance is hydrocortisone 15-20 mg daily in divided doses (typically 10 mg morning, 5 mg afternoon, 5 mg evening) 1, 2
• Patients should be educated on "sick day rules" to self-adjust dosing 1

Pediatric Dosing

• Give hydrocortisone 2 mg/kg IV at induction for any surgery under general anesthesia 1
• Following major surgery: hydrocortisone 2 mg/kg IV/IM every 4 hours, or continuous infusion 1
• After minor surgery: double the normal oral hydrocortisone dose 1
• No child with adrenal insufficiency should be fasted for more than 6 hours 1

Obstetric Patients

• At onset of active labor: hydrocortisone 100 mg IV bolus (when contractions every 5 minutes for 1 hour, or cervical dilation >4 cm) 1
• Follow with continuous infusion of 200 mg/24 hours, OR hydrocortisone 50 mg IM every 6 hours 1
• Rapid taper over 1-3 days to regular replacement dose after uncomplicated delivery 1

Critical Pitfalls to Avoid

• Never delay treatment while awaiting diagnostic confirmation—treat suspected adrenal crisis immediately 3
• Always start corticosteroids BEFORE other hormone replacements (thyroid, testosterone, estrogen), as these accelerate cortisol clearance and can precipitate adrenal crisis 1, 2
• For primary adrenal insufficiency, restart fludrocortisone 0.05-0.2 mg daily only when hydrocortisone dose falls below 50 mg/day (higher doses provide sufficient mineralocorticoid activity) 3
• Patients on chronic therapeutic steroids (≥5 mg prednisone equivalent for >1 month) should receive stress-dose coverage, as approximately one-third to one-half have inadequate adrenal reserve 1

Patient Education Requirements

• All patients must have emergency hydrocortisone injection kit (100 mg) for self-administration 2, 3
• Provide medical alert bracelet/necklace and steroid emergency card 1, 2, 3
• Train patient and family on stress dosing, emergency injection technique, and when to seek immediate medical attention 1, 2

Steroid Equivalencies

• Hydrocortisone 20 mg = Prednisone 5 mg = Dexamethasone 0.75 mg 1, 2
• Only hydrocortisone provides mineralocorticoid activity at physiologic doses 1