What is the stress dose of Solucortef (hydrocortisone)?

From the Guidelines

Solucortef stress dosing should be 100 mg IV at the start of surgery, followed by an infusion of 200 mg/24h, and then doubling the regular oral replacement dose of hydrocortisone for 48 h, and for up to a week following major surgery before the maintenance dose is resumed, as recommended by the most recent guidelines from the Association of Anaesthetists, the Royal College of Physicians, and the Society for Endocrinology UK 1.

Key Considerations

• The normal adrenal gland increases cortisol production up to 10-fold during physiologic stress, and patients with adrenal insufficiency cannot mount this response, putting them at risk for adrenal crisis without supplementation.
• Patients with a long-standing diagnosis of adrenal insufficiency are often well informed about their disease, and anaesthetists should enquire closely about the patient’s history of glucocorticoid self-management, any previous episodes of adrenal crisis, and how practised they are at medication adjustments for illness, injury, or postoperative recovery 1.
• Hydrocortisone 100 mg by intravenous injection should be given at induction of anaesthesia in adult patients with adrenal insufficiency from any cause, followed by a continuous infusion of hydrocortisone at 200 mg/24h-1, until the patient can take double their usual oral glucocorticoid dose by mouth 1.

Special Considerations

• Children with adrenal insufficiency are more vulnerable to problems with glycaemic control than adults and require frequent blood glucose monitoring, and can be treated with a bolus of hydrocortisone at induction of anaesthesia followed by an immediate continuous infusion of hydrocortisone, or alternatively with a bolus at induction followed by subsequent four hourly IV boluses of hydrocortisone in the postoperative period 1.
• Maternal glucocorticoid supplementation in obstetric patients with adrenal insufficiency represents another group who require special mention, and women may require a higher maintenance dose during the later stages of pregnancy (20th week onwards), and stress dose supplementation using hydrocortisone 100 mg at the onset of labour, and then either by continuous IV infusion of hydrocortisone 200 mg/24h-1 or 50 mg intramuscularly every 6 h until after delivery 1.

From the FDA Drug Label

DOSAGE AND ADMINISTRATION ... In certain overwhelming, acute, life-threatening situations, administration in dosages exceeding the usual dosages may be justified and may be in multiples of the oral dosages. The initial dose of SOLU-CORTEF Sterile Powder is 100 mg to 500 mg, depending on the specific disease entity being treated This dose may be repeated at intervals of 2,4, or 6 hours as indicated by the patient's response and clinical condition Situations that may make dosage adjustments necessary are changes in clinical status secondary to remissions or exacerbations in the disease process, the patient's individual drug responsiveness, and the effect of patient exposure to stressful situations not directly related to the disease entity under treatment 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.

The stress dose of Solucortef (hydrocortisone) can vary from 100 mg to 500 mg, depending on the specific situation and the patient's response. The dose may be repeated at intervals of 2,4, or 6 hours as needed. In stressful situations, it may be necessary to increase the dosage for a period of time consistent with the patient's condition 2.

• The dose may need to be adjusted based on the patient's individual response and clinical condition.
• The medication should be administered intravenously over a period of 30 seconds to 10 minutes.

From the Research

Solucortef Stress Dose

• Solucortef, also known as hydrocortisone, is a corticosteroid used to treat adrenal insufficiency, including during stressful events such as sepsis or surgery 3, 4.
• The dosage of hydrocortisone for stress doses can vary, but a common range is 200-300 mg/day, administered in divided doses or as a continuous infusion 3.
• In patients with septic shock, hydrocortisone should be started as early as possible to decrease the amount of time that vasopressors are required and mortality at 28 days 3.
• For patients who cannot undergo an adrenocorticotropic hormone (ACTH) stimulation test immediately, dexamethasone may be used until the test can be administered, as it does not interfere with the cortisol test 3.
• The use of extended-release hydrocortisone formulations may offer benefits such as improved quality of life, reduced body weight, blood pressure, and glucose levels, but it is still unclear if these benefits are due to differences in cortisol exposure or alterations in pharmacokinetics 5.
• Patients with secondary adrenal insufficiency who are susceptible to adrenal crisis may have differences in cortisol excretion and pharmacodynamics, suggesting a biological predisposition to adrenal crisis 6.
• Glucocorticoid replacement therapy in patients with adrenal insufficiency has been established for over 50 years, but current standard treatment regimens may not adequately replicate the natural circadian rhythm of cortisol release, leading to increased morbidity and decreased life expectancy 7.