What is the recommended stress dose steroid regimen for a patient with Addison's disease (adrenal insufficiency) facing a stressful situation?

Stress Dose Steroids for Addison's Disease

For patients with Addison's disease facing major physiological stress (severe illness, surgery, trauma), give hydrocortisone 100 mg IV bolus immediately, followed by continuous infusion of 200 mg over 24 hours until the patient can tolerate oral intake, then switch to double the usual oral maintenance dose for 48 hours to 1 week depending on stress severity. 1, 2, 3

Dosing by Stress Severity

Severe Stress (Adrenal Crisis, Major Surgery, Sepsis, Severe Trauma)

• Immediate treatment: Hydrocortisone 100 mg IV bolus at presentation 1
• Maintenance during crisis: Continuous IV infusion of 200 mg hydrocortisone over 24 hours 1, 2, 3
• Alternative if infusion unavailable: Hydrocortisone 50-100 mg IV/IM every 6 hours 1, 2, 3
• Do not delay treatment for diagnostic confirmation—if adrenal crisis is suspected, treat immediately as mortality is high without intervention 2, 3

Moderate Stress (Moderate Illness, Minor Surgery, Dental Procedures)

• Outpatient management: 2-3 times the maintenance dose (hydrocortisone 20-30 mg in morning, 10-20 mg in afternoon) 1, 4
• For procedures: Hydrocortisone 100 mg IM just before the procedure 1
• Postoperative: Double oral dose for 24-48 hours, then return to maintenance 1

Mild Stress (Febrile Illness, Minor Infections, "Sick Days")

• Simply double the usual oral maintenance dose for 24-48 hours 1, 2, 3
• Standard maintenance is hydrocortisone 15-25 mg daily in divided doses (typically 10-20 mg morning, 5-10 mg early afternoon) 1

Tapering After Stabilization

• When to start tapering: Once hemodynamically stable, tolerating oral intake, and off vasopressors 3, 4
• Switch to oral: Double the usual maintenance dose when stable 1, 3
• Duration of doubled dose: 48 hours for minor/moderate stress; up to 1 week for major surgery or complicated recovery 1, 2
• Final taper: Reduce stress-dose steroids down to maintenance over 5-7 days 1, 2

Special Populations

Obstetric Patients (Labor and Delivery)

• At onset of active labor: Hydrocortisone 100 mg IV bolus (when contractions every 5 minutes for 1 hour, or cervical dilation >4 cm) 3
• Maintenance during labor: Continuous infusion 200 mg/24 hours OR hydrocortisone 50 mg IM every 6 hours 1, 3
• Postpartum: Double oral dose for 24-48 hours after delivery 1

Pediatric Patients

• At induction of anesthesia: Hydrocortisone 2 mg/kg IV 3, 4
• After major surgery: Hydrocortisone 2 mg/kg IV/IM every 4 hours, or continuous infusion 3, 4
• Critical consideration: Children are more vulnerable to hypoglycemia and require frequent blood glucose monitoring 1

Major Surgery Protocol

• Preoperative: Hydrocortisone 100 mg IM just before anesthesia 1
• Intraoperative/postoperative: Continue 100 mg IV every 6 hours until able to eat and drink 1
• Recovery phase: Double oral dose for 48+ hours for rapid recovery; longer for prolonged recovery 1

Mineralocorticoid Replacement

• Primary adrenal insufficiency only: Add fludrocortisone 0.05-0.1 mg daily 1, 2
• During stress dosing: High-dose hydrocortisone (100 mg) provides adequate mineralocorticoid effect by saturating the enzyme that normally inactivates cortisol in the kidney 1
• Secondary adrenal insufficiency: Fludrocortisone is NOT needed as the renin-angiotensin system remains intact 1

Steroid Equivalencies

• Hydrocortisone 20 mg = Prednisone 5 mg = Dexamethasone 0.75 mg 2, 3, 4
• Hydrocortisone is preferred because it provides mineralocorticoid activity at physiologic doses 3, 4
• Dexamethasone caveat: Has NO mineralocorticoid activity and is inadequate for primary adrenal insufficiency 1

Critical Pitfalls to Avoid

Never Delay Treatment

• Treat first, diagnose later: If adrenal crisis is suspected, give hydrocortisone immediately—do not wait for cortisol levels or ACTH stimulation testing 2, 3, 4
• Draw blood for cortisol and ACTH before giving steroids if possible, but do not delay treatment 1

Hormone Replacement Sequence Matters

• ALWAYS start corticosteroids BEFORE other hormone replacements (thyroid hormone, testosterone, estrogen) 2, 3, 4
• These other hormones accelerate cortisol clearance and can precipitate adrenal crisis if given before adequate glucocorticoid coverage 2, 3, 4

Recognize Relative Adrenal Insufficiency

• Adrenal crisis symptoms can occur even when plasma cortisol levels appear normal or elevated—this is called "relative adrenal insufficiency" 2, 3
• During physiological stress, cortisol requirements increase up to 5-fold (from 20 mg/day to approximately 100 mg/day) 2, 3, 4

Intraoperative Hypotension

• Unexplained hypotension unresponsive to fluids and vasopressors warrants empiric hydrocortisone 100 mg IV, followed by 50 mg IV every 6 hours 3

Patient Education Requirements (Essential for Safety)

• Emergency injection kit: All patients must have hydrocortisone 100 mg for self-administration or family member administration 2, 3, 4
• Medical alert identification: Bracelet or necklace and steroid emergency card 1, 2
• Sick day rules: Written and verbal instructions on doubling doses during illness 1, 5
• 24-hour access: Patients should have access to on-call endocrinologist by phone 5
• Education for family and primary care: Relatives and general practitioners must understand stress dosing protocols 5

Monitoring During Treatment

• Clinical assessment is primary: Plasma ACTH and serum cortisol are NOT useful for dose adjustment during maintenance therapy 1
• Signs of over-replacement: Weight gain, insomnia, peripheral edema 1
• Signs of under-replacement: Lethargy, nausea, poor appetite, weight loss, increased pigmentation 1
• During crisis management: Monitor blood pressure, electrolytes (sodium, potassium), glucose, and renal function 1