Adjust Glucocorticoid Dose According to Severity of Illness or Magnitude of Stressor
STEP 1 — Gather Information
Assess for intercurrent illness, fever, inability to tolerate oral meds, upcoming surgery/trauma/delivery, or other stressors; record temperature, need for bedrest, antibiotics, vomiting, fasting, surgical type, and ability to retain oral medication.
STEP 2 — Rule In / Rule Out
Determine if stressor warrants glucocorticoid dose increase: fever ≥38°C, illness requiring bedrest/antibiotics, vomiting/trauma preventing oral intake, minor/moderate/major surgical stress, or delivery; if none, continue usual dose.
STEP 3 — Classify or Stratify
Classify stressor magnitude:
- Fever 38–38.9°C → double usual oral dose.
- Fever ≥39°C → triple usual oral dose.
- Unable to tolerate oral (vomiting, trauma, fasting for procedure) → give IM hydrocortisone (adult 100 mg, child 50 mg/m2, infant 25 mg) followed by continuous IV infusion 200 mg/24h (or 50 mg q6h).
- Minor/moderate surgical stress → hydrocortisone 25–75 mg/24h.
- Major surgery/trauma/delivery/ICU → hydrocortisone 100 mg IV bolus then continuous infusion 200 mg/24h.
STEP 4 — Decide
Administer the selected glucocorticoid regimen; if oral route possible, give divided doses with largest dose in morning; if parenteral, start with bolus then continuous infusion; reassess after 24h and taper to maintenance as clinical improvement occurs.
Clinical Guardrails / Mimics / Pitfalls
Do not delay stress dosing while awaiting diagnostic results; avoid dexamethasone for stress dosing due to lack of mineralocorticoid activity and risk of adrenal crisis; do not underdose in hypotension or shock; ensure fluid resuscitation with isotonic saline and dextrose; do not rely on ACTH or cortisol levels to adjust stress doses.
Concrete Clinical Example
A 45‑year‑old woman with PAI presents with fever 39.5°C and productive cough; she doubles her usual hydrocortisone dose (e.g., from 20 mg AM/10 mg noon to 40 mg AM/20 mg noon) and continues until afebrile 24h later, then tapers back to maintenance.
Source: Diagnosis and Treatment of Primary Adrenal Insufficiency, Endocrine Society, 2016, DOI: 10.1210/jc.2015-1710