Should a patient with newly diagnosed lung cancer and a history of adrenal insufficiency (AI) taking hydrocortisone (corticosteroid) 20 mg in the morning and 10 mg in the evening have their dose increased due to potential stress related to diagnosis and possible cancer treatment?

Should Hydrocortisone Be Increased for Newly Diagnosed Lung Cancer with Adrenal Insufficiency?

No, do not routinely increase hydrocortisone solely based on the diagnosis of lung cancer or the psychological stress of receiving a cancer diagnosis. The patient's current maintenance dose of 30 mg daily (20 mg AM, 10 mg PM) should be continued unless specific physiological stressors occur, such as active infection, surgery, chemotherapy complications, or symptoms of adrenal crisis 1.

Key Principle: Distinguish Psychological from Physiological Stress

• Psychological stress alone (anxiety, fear, emotional distress from diagnosis) does NOT require increased glucocorticoid dosing 1, 2.
• Physiological stress (infection, surgery, severe illness, chemotherapy side effects) DOES require dose adjustment 1, 3, 4.
• The cancer diagnosis itself, without active treatment or complications, represents emotional stress but not the type of physiological stress that increases cortisol requirements 1, 5.

When to Increase Hydrocortisone in This Patient

Major Stress Situations (Require Stress Dosing)

• Surgery for lung cancer: 100 mg hydrocortisone IV at induction of anesthesia, followed by 200 mg/24 hours as continuous infusion or 50-100 mg IV every 6-8 hours 1, 4.
• Chemotherapy complications: Severe nausea/vomiting preventing oral intake, febrile neutropenia, sepsis, or other severe infections require 100 mg IV hydrocortisone immediately plus continuous infusion 1, 2, 3.
• Adrenal crisis symptoms: Severe weakness, confusion, hypotension, abdominal pain, or inability to take oral medications require immediate 100 mg IV hydrocortisone 1, 2, 6, 3.

Moderate Stress Situations (Double or Triple Oral Dose)

• Mild to moderate chemotherapy side effects: Fever >38°C, significant nausea (but still able to take oral medications), or diarrhea warrant doubling the daily dose to 60 mg (40 mg AM, 20 mg PM) for 2-3 days 1, 2, 5, 3.
• Minor procedures: Bronchoscopy, port placement, or dental procedures require 100 mg hydrocortisone IM before the procedure and doubling oral dose for 24 hours 1, 2.

Critical Patient Education Requirements

All patients with adrenal insufficiency and cancer must receive comprehensive education immediately 1, 2, 6, 3:

• Stress dosing protocol: Double or triple oral hydrocortisone during fever, infection, severe nausea/vomiting, or other acute illness 1, 2, 5, 3.
• Emergency injectable hydrocortisone kit: Prescribe hydrocortisone 100 mg IM with self-injection training for situations where oral intake is impossible 1, 2, 6, 3.
• Medical alert identification: Wear a bracelet or necklace indicating adrenal insufficiency to trigger stress-dose corticosteroids by emergency medical services 1, 2, 6, 3.
• Warning signs of adrenal crisis: Severe weakness, confusion, persistent vomiting, severe abdominal pain, hypotension, or inability to take oral medications 1, 2, 3.

Special Considerations for Lung Cancer Patients

Paraneoplastic Cushing Syndrome Risk

• Small cell lung cancer (SCLC) can cause ectopic ACTH production, leading to Cushing syndrome rather than adrenal insufficiency 1.
• If this patient has SCLC, verify that her adrenal insufficiency diagnosis is accurate and not masked by ectopic ACTH secretion 1.
• Patients with SCLC and ectopic Cushing syndrome have increased mortality from chemotherapy-induced infections and require treatment of hypercortisolism before starting chemotherapy 1.

Bilateral Adrenal Metastases

• Lung cancer can metastasize to adrenal glands, potentially worsening existing adrenal insufficiency if >90% of adrenal tissue is destroyed 7.
• Monitor for worsening symptoms (increased fatigue, hypotension, hyponatremia) that might indicate progression of adrenal destruction requiring dose adjustment 7.

Immune Checkpoint Inhibitor Therapy

• If the patient receives immunotherapy (anti-PD-1, anti-PD-L1, anti-CTLA-4), monitor closely for immune-related hypophysitis causing secondary adrenal insufficiency 1.
• New or worsening symptoms during immunotherapy require urgent endocrine evaluation and may necessitate stress-dose steroids (hydrocortisone 50-100 mg IV every 6-8 hours) 1.

Coordination with Oncology Team

• Notify the oncology team about the patient's adrenal insufficiency before any cancer treatment begins 1.
• Endocrine consultation is recommended before surgery or initiation of chemotherapy to establish stress-dosing protocols 1, 2.
• Pre-operative planning: For surgical resection of lung cancer, the anesthesia and surgical teams must be informed to administer appropriate stress-dose hydrocortisone 1, 2.

Common Pitfalls to Avoid

• Do not increase hydrocortisone based solely on emotional distress or anxiety about the cancer diagnosis—this represents psychological, not physiological stress 1, 2.
• Do not delay stress dosing if the patient develops fever, infection, or severe chemotherapy side effects—early dose adjustment prevents adrenal crisis 1, 2, 3.
• Do not assume the patient knows how to manage stress dosing—explicit education and written instructions are mandatory 1, 2, 6, 3.
• Do not forget mineralocorticoid replacement if this patient has primary adrenal insufficiency—fludrocortisone 0.05-0.2 mg daily is required in addition to hydrocortisone 6, 5.

Monitoring During Cancer Treatment

• Assess for signs of under-replacement: Persistent fatigue, nausea, weight loss, hypotension, or hyponatremia may indicate inadequate dosing during treatment 2, 6, 7.
• Check electrolytes regularly during chemotherapy, as hyponatremia can result from both SIADH (common in lung cancer) and adrenal insufficiency 1, 8.
• Distinguish SIADH from adrenal insufficiency: Both cause hyponatremia, but adrenal insufficiency requires cosyntropin stimulation testing for definitive diagnosis if clinical uncertainty exists 8.