What is the recommended stress dose of corticosteroids (steroids) for a patient with adrenal insufficiency?

From the Guidelines

For patients with adrenal insufficiency who experience physiologic stress, stress-dose steroids are essential to prevent adrenal crisis, and the recommended regimen is hydrocortisone 100 mg intravenously at the start of surgery, followed by an infusion of 200 mg/24 h, as recommended by the guidelines from the Association of Anaesthetists, the Royal College of Physicians, and the Society for Endocrinology UK 1.

Key Points

• The guidelines recommend hydrocortisone 100 mg intravenously at induction, followed by a continuous infusion of hydrocortisone at 200 mg/24 h for patients with adrenal insufficiency undergoing major surgery 1.
• For patients with primary adrenal insufficiency, dexamethasone is not adequate as glucocorticoid treatment due to its lack of mineralocorticoid activity 1.
• Patients should receive their usual mineralocorticoid (fludrocortisone) if taking it chronically, and all patients with adrenal insufficiency should carry an emergency kit with injectable hydrocortisone, wear medical alert identification, and be educated on stress dosing 1.
• The recommended regimen for minor stress, such as mild febrile illness, is doubling or tripling the patient's usual daily oral glucocorticoid dose, and for moderate stress, such as minor surgery, hydrocortisone 25-50 mg IV/oral every 8 hours is recommended 1.

Administration and Monitoring

• Hydrocortisone should be administered parenterally in the peri-operative period until normal enteral function returns, and the traditional routes of administration are either via intramuscular injection or intravenous infusion 1.
• The plasma elimination half-time of exogenously administered hydrocortisone is approximately 90 minutes, and the volume of distribution of cortisol/hydrocortisone may be increased in critically ill patients 1.
• Patients taking drugs that induce CYP3A4, and obese adults, may require higher doses of hydrocortisone, and clinicians should maintain a high index of suspicion for adrenal crises in these patients and be prepared to immediately increase the dose if necessary 1.

From the FDA Drug Label

In this latter situation, it may be necessary to increase the dosage of the corticosteroid for a period of time consistent with the patient's condition.

• Adrenal insufficiency stress dose steroids: The FDA drug label suggests that in stressful situations, it may be necessary to increase the dosage of the corticosteroid for a period of time consistent with the patient's condition 2.
• The label does not provide a specific dosage for adrenal insufficiency stress dose steroids, but it implies that the dosage should be individualized based on the patient's response and clinical condition.

From the Research

Adrenal Insufficiency and Stress Dose Steroids

• Adrenal insufficiency requires increased hydrocortisone cover during major stress to avoid a life-threatening adrenal crisis 3.
• Current treatment recommendations are not evidence-based, and the optimal dose and duration of supplementation therapy have not been established 4.
• Patients with adrenal insufficiency should receive additional glucocorticoid doses during surgery or medical illness, with recommendations based on extrapolation from normal cortisol response to stress, expert opinion, and clinical experience 4.

Management of Adrenal Insufficiency

• Continuous intravenous hydrocortisone infusion is recommended for maintaining cortisol concentrations in the required range during major stress 3.
• The use of lower doses of glucocorticoids during surgical and medical stress is recommended, without de-emphasizing the importance of additional supplementation during such events 4.
• Patient education on stress dosing and parenteral glucocorticoid administration is crucial for preventing adrenal crisis 5.

Prevention and Emergency Management

• Omission of steroids in patients with adrenal insufficiency, particularly during physiological stress, can lead to adrenal crisis 6.
• A new NHS Steroid Emergency Card has been developed to be carried by patients at risk of adrenal crisis, and prompt recognition and administration of parenteral hydrocortisone are essential in emergency treatment 6, 5.
• Infections are a major precipitating factor for adrenal crisis, and other causes include physical stress, forgetting or discontinuing glucocorticoid therapy, pronounced physical activity, and psychological stress 5.