How should steroid replacement be modified in patients with chronic steroid replacement therapy during periods of stress, such as illness, injury, or surgery?

Modifying Steroid Replacement During Stress in Chronic Steroid Replacement

For major physiological stress (severe illness, major surgery, sepsis, trauma), immediately administer hydrocortisone 50-100 mg IV bolus followed by continuous infusion of 200 mg over 24 hours, or alternatively 50 mg IV/IM every 6 hours. 1, 2

Stress Severity-Based Dosing Algorithm

Major Stress (Severe illness, major surgery, sepsis, trauma, adrenal crisis)

Initial Management:

• Give hydrocortisone 100 mg IV bolus immediately 3
• Follow with continuous IV infusion of 200 mg hydrocortisone over 24 hours 1, 4
• Alternative if continuous infusion unavailable: hydrocortisone 50-100 mg IV/IM every 6-8 hours 3, 1, 5
• Administer 3-4 L isotonic saline with initial infusion rate of approximately 1 L/hour 3

Rationale: During major stress, cortisol requirements increase up to five-fold (approximately 100 mg/day) compared to normal daily production of 20 mg. 1, 2 Research demonstrates that continuous IV infusion is the only administration mode that persistently achieves median cortisol concentrations in the range observed during major stress. 4

Tapering Protocol:

• Once hemodynamically stable and tolerating oral intake, switch to oral hydrocortisone at double the usual maintenance dose 1, 2
• Taper stress-dose IV steroids down to oral maintenance doses over 5-7 days 3, 5
• Restart fludrocortisone when hydrocortisone dose falls below 50 mg/day 3

Moderate Stress (Moderate illness, minor procedures, dental work)

• Increase oral hydrocortisone to 2-3 times the maintenance dose 2
• Typical dosing: hydrocortisone 20-30 mg in morning and 10-20 mg in afternoon 2
• Maintain doubled dose for 48 hours after stress resolves 1, 2
• If unable to tolerate oral intake, give hydrocortisone 50 mg IM and seek medical attention 3

Minor Stress (Febrile illness, gastroenteritis, minor infections)

• Double the regular oral maintenance dose 1, 5
• Standard maintenance is hydrocortisone 15-20 mg daily in divided doses (typically 10 mg morning, 5 mg afternoon, 5 mg evening) 3, 1, 5
• Continue doubled dose for 48 hours after fever resolves 1

Special Populations

Obstetric Patients (Active Labor)

• At onset of active labor (contractions every 5 minutes for 1 hour, or cervical dilation >4 cm): hydrocortisone 100 mg IV bolus 1, 2
• Follow with continuous infusion of 200 mg/24 hours OR hydrocortisone 50 mg IM every 6 hours 1, 2

Pediatric Patients (Surgery)

• Give hydrocortisone 2 mg/kg IV at induction for any surgery under general anesthesia 1, 2
• Following major surgery: hydrocortisone 2 mg/kg IV/IM every 4 hours or continuous infusion 1, 2

Critical Pitfalls to Avoid

Never delay treatment while awaiting diagnostic confirmation—treat suspected adrenal crisis immediately. 1, 2, 5 Adrenal crisis carries significant mortality risk if untreated, and symptoms can occur even when plasma cortisol levels appear normal (relative adrenal insufficiency). 1, 5

Always start corticosteroids BEFORE initiating other hormone replacements (thyroid hormone, testosterone, estrogen), as these hormones accelerate cortisol clearance and can precipitate adrenal crisis. 3, 1, 2, 5

Do not underestimate stress requirements. Patients and physicians are often reluctant to increase glucocorticoid doses or switch to parenteral injections, leading to rapid deterioration and preventable deaths. 6 Gastrointestinal illness is the most common precipitant for adrenal crisis. 6

Steroid Equivalencies

• Hydrocortisone 20 mg = Prednisone 5 mg = Dexamethasone 0.75 mg 3, 1, 2, 5
• Hydrocortisone is the drug of choice because it provides mineralocorticoid activity at physiologic doses 1, 2
• Long-acting steroids (prednisone, dexamethasone) carry risk of over-replacement but can be used if adherence to short-acting regimen is not feasible 3

Essential Patient Education Requirements

All patients with adrenal insufficiency must have: 3, 1, 2, 5

• Emergency hydrocortisone injection kit (100 mg) for self-administration
• Medical alert bracelet/necklace identifying adrenal insufficiency
• Steroid emergency card with dosing instructions
• Clear instructions on when to double doses during illness
• Education on when to seek emergency medical care before becoming unable to self-care 3

Monitoring During Stress Dosing

• Frequent hemodynamic monitoring to avoid fluid overload 3
• Measure serum electrolytes regularly 3
• Consider ICU admission depending on severity of intercurrent illness 3
• Prophylaxis for gastric stress ulcer and DVT with low-dose heparin 3