Stress Dose Corticosteroids

Stress dose corticosteroids replace the cortisol response that a patient with adrenal insufficiency cannot mount during serious illness, surgery or trauma. Adrenal crisis is a medical emergency with hypotension, vomiting, hyponatraemia, hyperkalaemia and hypoglycaemia, and treatment starts before test results.

Who is at risk. Primary adrenal insufficiency, pituitary disease, and anyone who has taken prednisolone 5 mg daily or the equivalent for over 3 to 4 weeks, or higher doses for a shorter time, in the past 3 months. Inhaled, topical and injected steroids can suppress the axis if the dose is high or prolonged.

Equivalents. Hydrocortisone 20 mg equals prednisolone 5 mg and dexamethasone 0.75 mg. Only hydrocortisone has useful mineralocorticoid action.

Septic shock. Hydrocortisone is added when noradrenaline is needed at 0.25 micrograms/kg/min or more for at least 4 hours.

Adrenal crisis. Hydrocortisone intravenously, with isotonic saline and glucose. Draw a cortisol and sodium sample if possible, without delaying treatment.

Surgery. Dose by the size of the procedure. Hydrocortisone is the usual drug. Dexamethasone 4 mg intravenously can be used when cortisol testing is planned.

Sick days (oral replacement). Double the oral dose for fever over 38 degrees Celsius, and triple it for fever over 39 degrees. Give hydrocortisone 100 mg intramuscularly for vomiting or collapse.

Special groups.

• Children: hydrocortisone 25 mg (under 3 years), 50 mg (3 to 12 years) or 100 mg (over 12 years) intravenously, then 100 mg/m2 daily.

• Pregnancy and labour: hydrocortisone 100 mg intravenously at the onset of labour, then 6-hourly doses as needed.

• Drug interactions: rifampicin, phenytoin and carbamazepine speed steroid metabolism, so increase replacement doses.

• East Africa: tuberculosis and HIV-related infections are recognised causes of adrenal failure, and unregulated steroid-containing products or injections should be asked about.

• Adrenal crisis: hydrocortisone 100 mg intravenously or intramuscularly at once, then 200 mg over 24 hours by continuous infusion, or 50 mg every 6 hours. Give 1 L of 0.9 percent saline in the first hour, then continue by volume status. Treat low glucose.

• Major surgery or critical illness: hydrocortisone 100 mg at induction, then 200 mg over 24 hours for 24 to 48 hours, then double the usual oral dose until recovered.

• Minor or moderate procedures: hydrocortisone 25 to 50 mg intravenously at induction, then the usual oral dose.

• Septic shock: hydrocortisone 200 mg daily (50 mg every 6 hours), with fludrocortisone 50 micrograms daily optional.

• Fludrocortisone: no extra dose is needed when hydrocortisone is 50 mg or more daily.

Monitoring. Check blood pressure, glucose, sodium and potassium at least every 4 to 6 hours in a crisis, and every shift in sustained illness.

Stop rules. In septic shock stop hydrocortisone when vasopressors are off, with no taper needed. Return to the usual oral dose within 3 to 7 days after surgery or illness. Do not stop long-term steroids abruptly.

Referral and escalation. Seek endocrine advice for new adrenal insufficiency, failure to respond to hydrocortisone, and perioperative planning.

Common errors. Waiting for cortisol results, giving too little fluid, forgetting stress doses for steroid users, and stopping long-term steroids at admission.