Stress Dose Steroids Recommendations

Dosing Based on Severity

For patients with severe symptoms, the American College of Physicians recommends administering hydrocortisone 50-100 mg intravenously every 6-8 hours, with tapering to maintenance doses over 5-7 days 1, 2
For patients with mild symptoms, initiate replacement therapy with hydrocortisone 15-20 mg in divided doses, with a maximum of 30 mg daily total dose for residual symptoms of adrenal insufficiency 2, 3
For patients with primary adrenal insufficiency, add fludrocortisone 0.05-0.1 mg/day 1

Hydrocortisone 20 mg is equivalent to prednisone 5 mg, according to the American College of Clinical Endocrinologists 2

All patients need education on stress dosing for sick days, use of emergency injectables, and medical alert identification, as recommended by the American College of Physicians 2, 5
During physiological stress, cortisol requirements increase up to five-fold, approximately 100 mg/day, compared to normal daily production of 20 mg 5
Patients with comorbidities such as asthma and diabetes are more vulnerable to adrenal crisis, according to the American Academy of Allergy, Asthma, and Immunology 5

Consider endocrine consultation for recovery and weaning protocols in patients with symptoms of adrenal insufficiency after weaning off corticosteroids, as recommended by the American College of Clinical Endocrinologists 4

Starting other hormone replacements before corticosteroids can precipitate adrenal crisis, as other hormones accelerate cortisol clearance, according to the American College of Clinical Endocrinologists 4, 6
Adrenal crisis symptoms can occur in physiologically stressed patients while plasma cortisol levels are normal or even high, a condition known as relative adrenal insufficiency 5
Mortality risk is significantly higher in patients with untreated adrenal insufficiency, according to the American College of Physicians 5