Corticosteroid Stress Dosing

Introduction to Corticosteroid Stress Dosing

• The American College of Clinical Endocrinologists recommends administering hydrocortisone 50-100 mg IV bolus for major physiological stress, followed by continuous infusion of 200 mg in 24 hours 1, 2, 3
• The normal daily production of cortisol is approximately 20 mg/day, but during major physiological stress, requirements increase up to five times (approximately 100 mg/day) 1, 3

Dosage by Stress Severity

• For major stress (major surgery, sepsis, severe trauma), the recommended dosage is hydrocortisone 50-100 mg IV bolus, followed by continuous infusion of 200 mg in 24 hours 1, 2, 3
• For moderate symptoms, use 2-3 times the maintenance dose (hydrocortisone 20-30 mg in the morning and 10-20 mg in the afternoon) 4, 5
• For mild stress, simply double the usual maintenance dose 2, 3

Special Populations

• For obstetric patients, administer hydrocortisone 100 mg IV bolus at the onset of active labor, followed by continuous infusion of 200 mg/24h or hydrocortisone 50 mg IM every 6 hours 2
• For pediatric patients, administer hydrocortisone 2 mg/kg IV at induction for any surgery under general anesthesia, and after major surgery, administer hydrocortisone 2 mg/kg IV/IM every 4 hours or continuous infusion 2

Steroid Equivalencies

• Hydrocortisone 20 mg = prednisone 5 mg = dexamethasone 0.75 mg 2, 3
• Hydrocortisone is the drug of choice because it provides mineralocorticoid activity at physiological doses 2, 3

Reduction After Stabilization

• Start reduction when the patient is hemodynamically stable, tolerating oral intake, and off vasopressors 3
• Change to oral hydrocortisone at twice the maintenance dose when stable 2, 3
• Continue oral doubled dose for 48 hours to 1 week depending on stress severity 2, 3

Critical Traps to Avoid

• NEVER delay treatment waiting for diagnostic confirmation—treat suspected adrenal crisis immediately 3
• ALWAYS start corticosteroids BEFORE other hormone replacements (thyroid, testosterone, estrogen), as these hormones accelerate cortisol clearance and may precipitate adrenal crisis 4, 6, 1, 2, 3

Patient Education Requirements

• All patients with adrenal insufficiency should have a hydrocortisone emergency injection kit (100 mg) for self-administration 2
• Medical alert bracelet/collar and steroid emergency card 2
• Instructions on dosing during illness days 6
• Education on when to seek emergency care 6