Stress Dose Steroids Strategy

Initial Dosing by Clinical Severity

For patients with adrenal insufficiency experiencing major physiological stress, the American College of Anaesthesia recommends administering hydrocortisone 50-100 mg IV bolus immediately, followed by continuous IV infusion of 200 mg over 24 hours 1
The Endocrine Society suggests that if continuous infusion is unavailable, hydrocortisone 50 mg IV/IM every 6 hours can be used 1
Full-dose therapy should be continued for a minimum of 3 days or until vasopressors are no longer required, as recommended by the Praxis Medical Insights 3

The normal daily cortisol production is 20 mg/day, and during major stress, cortisol requirements increase five-fold to approximately 100 mg/day, according to the Praxis Medical Insights 5
Doses greater than 400 mg/day for less than 3 days show no benefit and potential harm, as stated by the Praxis Medical Insights 3

Hydrocortisone is the drug of choice because it provides mineralocorticoid activity at physiologic doses, as recommended by the Praxis Medical Insights 2
Dexamethasone 8 mg is equivalent to hydrocortisone 200 mg, but lacks mineralocorticoid activity and is inadequate for primary adrenal insufficiency, according to the Anaesthesia journal 1

Hydrocortisone 20 mg is equivalent to prednisone 5 mg and dexamethasone 0.75 mg, as stated by the Journal of Clinical Oncology 6

Tapering should start when the patient is hemodynamically stable, tolerating oral intake, and vasopressors are discontinued, as recommended by the Praxis Medical Insights 2
The taper protocol should involve switching to oral hydrocortisone at double maintenance dose when stable, and continuing the doubled oral dose for 48 hours to 1 week, according to the Praxis Medical Insights 2

For perioperative patients, minor surgery does not require stress dosing, while major surgery requires hydrocortisone 50-100 mg IV at induction, followed by 200 mg/24h continuous infusion, as recommended by the Anaesthesia journal 1
For obstetric patients, hydrocortisone 100 mg IV bolus should be administered at the onset of active labor, followed by 200 mg/24h continuous infusion or 50 mg IM every 6 hours, according to the Praxis Medical Insights 2

Primary adrenal insufficiency requires both glucocorticoid and mineralocorticoid replacement, with the addition of fludrocortisone 0.05-0.1 mg/day to hydrocortisone regimen, as recommended by the Journal of Clinical Oncology 4
Secondary adrenal insufficiency requires glucocorticoid replacement only, and corticosteroids should be started before other hormone replacements, according to the Journal of Clinical Oncology 6

Hydrocortisone is preferred for physiologic replacement, with 2/3 of the daily dose given in the morning and 1/3 in the early afternoon, as recommended by the Journal of Clinical Oncology 6

Treatment should not be delayed for suspected adrenal crisis, and mortality risk is significantly higher in untreated adrenal insufficiency, according to the Praxis Medical Insights 5
Bolus-only regimens for major stress should be avoided, as they create subtherapeutic troughs between doses, as stated by the Praxis Medical Insights 3

Patients should be educated on the use of an emergency hydrocortisone injection kit, medical alert bracelet/necklace, stress dosing instructions, and when to seek emergency care, as recommended by the Praxis Medical Insights 5

Expected adverse effects include hyperglycemia, hypernatremia, and no increased risk of secondary infections or GI bleeding, according to the Praxis Medical Insights 3