What are the indications for stress dose corticosteroids (steroids)?

From the Guidelines

Stress dose corticosteroids are indicated for patients with adrenal insufficiency who are experiencing physiologic stress, such as surgery, trauma, severe illness, or sepsis, to prevent adrenal crisis and reduce morbidity, mortality, and improve quality of life. The indications for stress dose corticosteroids include patients who have been on chronic steroid therapy, typically prednisone >5 mg daily or equivalent for more than 2-3 weeks within the past year, as well as those with primary or secondary adrenal insufficiency 1. Key points to consider when administering stress dose corticosteroids include:

• The standard regimen is hydrocortisone 100 mg intravenously at the start of surgery, followed by an infusion of 200 mg/24h 1
• For patients who are recovering well after surgery, the regular oral replacement dose of hydrocortisone should be doubled for 48 hours, and for up to a week following major surgery before the maintenance dose is resumed 1
• Patients with comorbidities, such as asthma and diabetes, are more vulnerable to adrenal crisis and may require closer monitoring and adjustment of their stress dose corticosteroid regimen 1
• The duration of stress dose corticosteroid coverage depends on the stressful event, typically continuing until the patient stabilizes, then tapering back to maintenance doses over 1-3 days 1
• Stress dosing is necessary because chronic exogenous steroid use suppresses the hypothalamic-pituitary-adrenal axis, preventing the normal physiologic increase in cortisol production during stress, and without supplementation, these patients may develop hypotension, shock, electrolyte abnormalities, and even death due to inadequate cortisol response to stress 1

From the FDA Drug Label

Increased dosage of rapidly acting corticosteroids is indicated in patients on corticosteroid therapy who are subjected to any unusual stress before, during, and after the stressful situation Increased dosage of rapidly acting corticosteroids is indicated in patients on corticosteroid therapy subjected to any unusual stress before, during and after the stressful situation Increased dosage of rapidly acting corticosteroids is indicated in patients on corticosteroid therapy subjected to any unusual stress before, during, and after the stressful situation

The indications for stress dose corticosteroids (steroids) are for patients on corticosteroid therapy who are subjected to any unusual stress. This includes situations such as:

• Trauma
• Surgery
• Infection
• Any other stressful event that may cause an adrenal crisis in a patient with impaired adrenal function due to chronic corticosteroid use 2, 3, 4.

Stress dose corticosteroids are used to prevent adrenal insufficiency in patients who are chronically taking corticosteroids and are experiencing stress.

From the Research

Indications for Stress Dose Corticosteroids

The indications for stress dose corticosteroids (steroids) include:

• Major stress conditions such as major trauma, sepsis, and combat stress 5
• Surgery, particularly elective surgery 5, 6
• Medical illness, especially those that cause significant stress to the body 6
• Intensive endurance exercise in patients with primary adrenal insufficiency 7
• Perioperative period for patients on chronic glucocorticoid therapy, with the need for stress dose steroids based on patient risk of adrenal suppression and surgical complexity and stress 8
• Critically ill patients, particularly those with septic shock, who may require low-dose corticosteroids for a longer duration 9

Specific Conditions Requiring Stress Dose Corticosteroids

Some specific conditions that may require stress dose corticosteroids include:

• Adrenal insufficiency, particularly primary adrenal insufficiency 5, 7
• Adrenal crisis, which can be life-threatening if not treated promptly 5
• Sepsis, which can cause significant stress to the body and require corticosteroid therapy 5, 9
• Major trauma, which can also cause significant stress and require corticosteroid therapy 5

Dosage and Administration

The dosage and administration of stress dose corticosteroids may vary depending on the specific condition and patient needs. However, some studies suggest that:

• Continuous intravenous hydrocortisone infusion may be the most effective mode of administration in patients with adrenal insufficiency exposed to major stress 5
• Lower doses of glucocorticoids may be sufficient during surgical and medical stress, rather than the high doses traditionally used 6
• Hydrocortisone 200-300 mg/day, administered in divided doses or as a continuous infusion, may be the preferred corticosteroid in patients with septic shock 9