What is the recommended dosage and administration of stress dose steroids, such as hydrocortisone (corticosteroid) or methylprednisolone (corticosteroid), for patients requiring stress dose steroid therapy?

Stress Dose Steroids: Dosing and Administration

Primary Recommendation

For patients with adrenal insufficiency experiencing major physiological stress (surgery, sepsis, trauma), administer hydrocortisone 50-100 mg IV bolus immediately, followed by continuous IV infusion of 200 mg over 24 hours. 1 This is the preferred delivery method as it most reliably maintains cortisol concentrations in the physiologic stress range compared to intermittent bolus dosing. 2

Clinical Context: When Stress Dosing is Required

Patients Who Need Stress Dosing

• Known adrenal insufficiency (primary or secondary) requiring physiologic replacement therapy 1
• Intraoperative hypotension unresponsive to fluids and vasopressors should trigger rescue dose of 100 mg hydrocortisone IV, followed by 50 mg IV every 6 hours 3

Patients Who Do NOT Need Stress Dosing

• Patients on chronic therapeutic corticosteroids (≤20 mg/day prednisone equivalent) should continue their usual daily dose rather than receiving supra-physiologic stress dosing during acute medical illness 4, 5
• Low-quality evidence shows no hemodynamic difference between continuing usual dose versus stress dosing in these patients 4

Dosing Algorithms by Clinical Scenario

Major Stress (Surgery, Sepsis, Trauma)

Initial bolus: Hydrocortisone 50-100 mg IV at onset of stress 1

Maintenance (choose one):

• Preferred: Continuous IV infusion 200 mg hydrocortisone over 24 hours 1, 2
• Alternative: Hydrocortisone 50 mg IV/IM every 6 hours if continuous infusion unavailable 1

Rationale: During major stress, cortisol requirements increase five-fold to approximately 100 mg/day compared to normal production of 20 mg/day 6, 1. Continuous infusion is the only delivery mode that persistently achieves median cortisol concentrations in the range observed during major stress. 2

Tapering After Stabilization

Once hemodynamically stable and tolerating oral intake:

• Switch to oral hydrocortisone at double the usual maintenance dose 1
• Continue doubled dose for 48 hours after minor/moderate stress 1
• Continue doubled dose for up to 1 week following major surgery 1
• Taper IV stress-dose steroids to oral maintenance over 5-7 days 6, 1

Mild to Moderate Stress (Febrile Illness, Minor Procedures)

• Double the regular oral maintenance dose 1
• Standard maintenance is hydrocortisone 15-20 mg daily in divided doses 6, 1

Pediatric Dosing

Any surgery under general anesthesia:

• Hydrocortisone 2 mg/kg IV at induction 1

Following major surgery:

• Hydrocortisone 2 mg/kg IV/IM every 4 hours, or continuous infusion 1

Obstetric Patients

At onset of active labor (contractions every 5 minutes for 1 hour, or cervical dilation >4 cm):

• Hydrocortisone 100 mg IV bolus 1
• Follow with continuous infusion 200 mg/24 hours, OR hydrocortisone 50 mg IM every 6 hours 1

Drug Selection and Equivalencies

Preferred Agent

Hydrocortisone is the drug of choice for stress and rescue dose coverage 3, 1

• Only hydrocortisone provides mineralocorticoid activity at physiologic doses 1

Steroid Equivalencies

• Hydrocortisone 20 mg = Prednisone 5 mg = Dexamethasone 0.75 mg 1
• Hydrocortisone 20 mg = Prednisolone 5 mg 7
• Methylprednisolone 4 mg = Prednisolone 5 mg 8

Alternative Agents

Growing evidence suggests dexamethasone may be used as it has no mineralocorticoid activity and likely provides the same protective effect in short courses 3

Critical Pitfalls to Avoid

Never Delay Treatment

• Treat suspected adrenal crisis immediately without waiting for diagnostic confirmation 1
• Unexplained intraoperative or postoperative hypotension despite fluids and vasopressors warrants empiric hydrocortisone 3

Hormone Replacement Sequencing

• Always start corticosteroids BEFORE other hormone replacements (thyroid, testosterone, estrogen) 6, 1
• Other hormones accelerate cortisol clearance and can precipitate adrenal crisis 6, 1

Avoid Unnecessary Stress Dosing

• Do not routinely give stress doses to patients on chronic therapeutic steroids who continue their usual daily dose 4, 5
• Unnecessarily increasing steroid dose increases infection risk in already vulnerable patients 4
• Adrenal function testing is overly sensitive and does not predict who will develop adrenal crisis 5

Recognize Relative Adrenal Insufficiency

• Adrenal crisis symptoms can occur even when plasma cortisol levels appear normal or elevated (relative adrenal insufficiency) 6, 1
• This makes empiric dosing critical in unstable patients 1

Patient Education Requirements

All patients with adrenal insufficiency require:

• Emergency hydrocortisone injection kit (100 mg) for self-administration 1
• Medical alert bracelet/necklace and steroid emergency card 6, 1
• Education on stress dosing for sick days and use of emergency injectables 6

Special Populations

Primary Adrenal Insufficiency

• Add fludrocortisone 0.05-0.1 mg/day to hydrocortisone regimen 6

Patients with Comorbidities

• Those with asthma and diabetes are more vulnerable to adrenal crisis 6
• Lower threshold for stress dosing in these populations 6

Alternative Routes When IV Access Unavailable

• Rectal hydrocortisone 100 mg/m² achieves mean serum cortisol of 1212 nmol/L at 3 hours, reaching 1000 nmol/L by 1 hour 9
• However, 8 of 57 children failed to achieve adequate levels (>600 nmol/L), so this route should only be used after documenting adequate response to a test dose 9

Monitoring and Follow-up

• Consider endocrine consultation for recovery and weaning protocols in patients with symptoms of adrenal insufficiency after weaning off corticosteroids 6
• Mortality risk is significantly higher in untreated adrenal insufficiency 6