What stress‑dose glucocorticoid regimen should be used for a patient receiving chronic prednisone (≥5 mg daily for >2–3 weeks) who is facing major physiologic stress such as surgery, severe infection, or trauma?

Stress-Dose Glucocorticoid Protocol for Chronic Prednisone Users

For patients on chronic prednisone ≥5 mg daily for >2-3 weeks facing major physiologic stress (surgery, severe infection, trauma), administer hydrocortisone 50-100 mg IV bolus immediately, followed by continuous infusion of 200 mg over 24 hours (or alternatively 50 mg IV/IM every 6 hours). 1

Why This Aggressive Approach is Necessary

The evidence strongly supports empiric stress-dosing even when adrenal function seems adequate:

• Adrenal insufficiency is extremely common in chronic low-dose prednisone users: 39-48% of patients on just 5 mg prednisone daily have documented adrenal insufficiency on testing 2
• "Relative adrenal insufficiency" can occur even with normal or elevated cortisol levels during physiologic stress, making laboratory values unreliable for real-time decision-making 1, 3
• Cortisol requirements increase five-fold (to ~100 mg/day) during major stress compared to normal daily production of 20 mg 1, 3
• The consequences of under-treatment are severe: mortality risk is 2-3 times higher in patients with adrenal insufficiency, and adrenal crises occur at 6-8 per 100 patient-years 4, 3

Initial Management Algorithm

For Major Stress (Surgery, Severe Infection, Trauma):

Immediate dosing:

• Hydrocortisone 100 mg IV bolus at onset of stress 1, 3
• Follow immediately with continuous infusion of 200 mg hydrocortisone over 24 hours 1
• Alternative if continuous infusion unavailable: Hydrocortisone 50 mg IV/IM every 6 hours 1

Why hydrocortisone specifically?

• Hydrocortisone is the drug of choice because it provides mineralocorticoid activity at physiologic doses 1
• Dexamethasone 6-8 mg IV may substitute and provides 24-hour coverage, but should NOT be used if primary adrenal insufficiency is suspected (lacks mineralocorticoid activity) 4

For Moderate Stress (Minor Procedures, Febrile Illness):

• Double the patient's regular oral prednisone dose 1, 4
• Continue doubled dose for 48 hours after stress resolution 1, 4

Transitioning and Tapering

Once hemodynamically stable and tolerating oral intake:

• Switch to oral hydrocortisone at double the usual maintenance dose 1, 3
• Continue doubled oral dose for 48 hours (uncomplicated recovery) to 1 week (major surgery or complications) 1, 4
• Can convert to prednisone using 5:1 equivalency ratio (20 mg hydrocortisone = 5 mg prednisone) 1, 4

If patient remains unstable:

• Continue IV hydrocortisone infusion until clinical stability achieved 4, 3

Critical Pitfalls to Avoid

• Never delay treatment awaiting diagnostic confirmation—treat suspected adrenal crisis immediately 1, 3
• Do not withhold stress-dose steroids based solely on preoperative cortisol levels, as surgical stress requires supplementation even with borderline-normal function 4
• Do not rely on hypotension response to diagnose adrenal insufficiency—hypotension can occur from other causes, and adrenal crisis can present without hypotension 5
• Never abruptly discontinue steroids postoperatively—taper gradually over 48 hours to 1 week 4

The Controversy: Is This Much Steroid Really Needed?

There is conflicting evidence on this topic:

Conservative evidence: One small randomized trial found that patients with secondary adrenal insufficiency did NOT experience hypotension when given only their usual daily prednisone dose during surgery (no additional stress dosing) 6. However, this study had only 18 patients and most received major operations.

Guideline consensus favors aggressive dosing: Despite this single study, all major guidelines (American College of Anaesthesiologists, Association of Anaesthetists, Royal College of Physicians, Endocrine Society) recommend the full stress-dose protocol 1, 4, 3. The rationale: short-term glucocorticoid administration has no long-term adverse consequences, while under-treatment can be fatal 4.

In real-world clinical practice, err on the side of administering stress-dose steroids if there is any doubt, as the risk-benefit ratio strongly favors treatment 4.

Patient Education and Prevention

All patients on chronic prednisone should have:

• Emergency hydrocortisone injection kit (100 mg) for self-administration 1, 3, 7
• Medical alert bracelet/necklace and steroid emergency card 1, 3
• Clear instructions on doubling oral doses during illness 1, 7

Steroid Equivalencies for Reference

• Hydrocortisone 20 mg = Prednisone 5 mg = Dexamethasone 0.75 mg 1
• Use these conversions when transitioning between formulations 1, 4