Table 8: Open in new tab Suggested...

General considerations

Examples

Suggested regimen

Minor stress

If the patient is already taking hydrocortisone ≥40 mg daily prednisone ≥10 mg daily, or dexamethasone ≥1 mg daily, there is typically no need to increase the dose unless there are signs of hemodynamic instability.

Illness requiring bed rest
Illness with fever (out of hospital)
Illness requiring treatment with antibiotics (out of hospital)
Significant emotional stress (e.g., bereavement)

If not on daily glucocorticoids: give hydrocortisone 40 mg total daily dose, to be given in three divided doses (e.g., 20 mg on rising, 10 mg 12 midday, 10 mg 5pm). Continue for 2-5 days until well (or for the duration of antibiotic treatment).
If on hydrocortisone <40 mg total daily dose: increase to 40 mg total daily dose, to be given in three divided doses (e.g., 20 mg on rising, 10 mg 12 midday, 10 mg 5pm). Continue for 2-5 days until well (or for the duration of antibiotic treatment).
If on prednisone <10 mg total daily dose: increase to 10 mg total daily dose, to be given in one or two divided doses. Continue for 2-5 days until well (or for the duration of antibiotic treatment).
If on dexamethasone <1 mg total daily dose: increase to 1 mg once daily. Continue for 2-5 days until well.

Minor surgery including any procedure requiring local anesthesia

If not on daily glucocorticoids: give oral hydrocortisone 40 mg total daily dose, to be given in three divided doses (e.g., 20 mg one hour prior to the procedure, 10 mg six hours after the procedure, 10 mg after a further six hours). Continue glucocorticoids in patients who remain unwell after the procedure until clinically stable.
If on hydrocortisone <40 mg total daily dose: increase to 40 mg total daily dose, to be given in three divided doses (e.g., 20 mg one hour prior to the procedure, 10 mg six hours after the procedure, 10 mg after a further six hours). Continue increased dose in patients who remain unwell after the procedure until clinically stable.
If on prednisone <10 mg total daily dose: increase to 10 mg total daily dose, to be given one hour prior to the procedure. Continue increased dose in patients who remain unwell after the procedure until clinically stable.
If on dexamethasone <1 mg total daily dose: increase to 1 mg total daily dose, to be given one hour prior to the procedure. Continue increased dose in patients who remain unwell after the procedure until clinically stable.

Bowel procedures not carried out under general anesthesia

If not on daily glucocorticoids: give hydrocortisone 20 mg total daily dose, to be given in three divided doses (e.g., 10 mg one hour prior to the procedure, 5 mg six hours after the procedure, 5 mg after a further six hours).
If on daily glucocorticoids: continue normal glucocorticoid dose. Give an equivalent I.V. dose if prolonged nil by mouth.

Moderate and major stress

If the patient is already taking hydrocortisone ≥200 mg daily, prednisone ≥50 mg daily, or dexamethasone ≥6-8 mg daily, there is typically no need to increase the dose
In patients with suspected reduced absorption (persistent vomiting or diarrhea), nil by mouth, or unable to take tablets, give stress-dose glucocorticoids I.V. or I.M.
High body weight can be taken into consideration as a factor indicating higher dosage requirements.

Severe intercurrent illness, for example:

Persistent vomiting or diarrhea from gastro-intestinal illness.
Infection requiring hospital admission or I.V. antibiotics (e.g., sepsis).
Acute trauma resulting in significant blood loss or hospital admission.

For patients with persistent vomiting or diarrhea who are well enough to remain out of hospital: Hydrocortisone 100 mg I.M. injection immediately, which can be repeated after 6 hours if needed. If symptoms do not resolve or hemodynamic instability develops, admit to hospital for I.V. urgent glucocorticoid and fluid administration.
Patients requiring hospital admission: Hydrocortisone 100 mg I.V. bolus or I.M. injection immediately, followed by immediate initiation of a continuous infusion of hydrocortisone 200 mg over 24 h. If a continuous infusion is not feasible, give hydrocortisone 50 mg I.V. boluses every 6 hours. The duration and dose of the glucocorticoid regimen thereafter must be individualized based on the stressor type and the patient’s clinical status.

Surgery or any procedure requiring general or regional anesthesia with anticipated short recovery time and no nil by mouth

Intra-operative regimen: Hydrocortisone 100 mg I.V. bolus at induction, followed by immediate initiation of a continuous infusion of hydrocortisone 200 mg over 24 h. If a continuous infusion is not feasible, give hydrocortisone 50 mg I.V. boluses every 6 hours.
Postoperative regimen: Resume oral glucocorticoids at an increased dose for 48 h (e.g., hydrocortisone 40 mg/daily in three divided doses; prednisone 10 mg/daily in one or two divided doses; dexamethasone 1 mg once daily) and then resume the pre-surgical dose. In case of post-operative complications (e.g., significant pain, infections), maintain an increased oral dose or give stress-dose glucocorticoids I.V. as clinically appropriate.

Surgery (including cesarean section) or any procedure requiring general or regional anesthesia with nil by mouth or expected long recovery time

Intra-operative regimen: Hydrocortisone 100 mg I.V. bolus at induction, followed by immediate initiation of a continuous infusion of hydrocortisone 200 mg over 24 h. If a continuous infusion is not feasible, give hydrocortisone 50 mg I.V. boluses every 6 hours.
Postoperative regimen: Continuous infusion of hydrocortisone 200 mg over 24 h while the patient is nil by mouth. If a continuous infusion is not feasible, give hydrocortisone 50 mg I.V. boluses every 6 hours. If the post-operative period is uncomplicated and once the patient can eat, resume oral glucocorticoids at an increased dose for 48 h (e.g., hydrocortisone 40 mg/daily in three divided doses; prednisone 10 mg/daily in one or two divided doses; dexamethasone 1 mg once daily) and then resume the pre-surgical dose. In case of post-operative complications (e.g., significant pain, infections), maintain an increased oral dose or give stress-dose glucocorticoids I.V. as clinically appropriate.

Labor and vaginal delivery

Hydrocortisone 100 mg I.V. bolus at onset of labor, followed by immediate initiation of a continuous infusion of hydrocortisone 200 mg over 24 h. If a continuous infusion is not feasible, give hydrocortisone 50 mg I.V. boluses every 6 hours.

General considerations

Examples

Suggested regimen

Minor stress

Illness requiring bed rest
Illness with fever (out of hospital)
Illness requiring treatment with antibiotics (out of hospital)
Significant emotional stress (e.g., bereavement)

Minor surgery including any procedure requiring local anesthesia

Bowel procedures not carried out under general anesthesia

Moderate and major stress

Severe intercurrent illness, for example:

Persistent vomiting or diarrhea from gastro-intestinal illness.
Infection requiring hospital admission or I.V. antibiotics (e.g., sepsis).
Acute trauma resulting in significant blood loss or hospital admission.

Surgery or any procedure requiring general or regional anesthesia with anticipated short recovery time and no nil by mouth

Surgery (including cesarean section) or any procedure requiring general or regional anesthesia with nil by mouth or expected long recovery time

Intra-operative regimen: Hydrocortisone 100 mg I.V. bolus at induction, followed by immediate initiation of a continuous infusion of hydrocortisone 200 mg over 24 h. If a continuous infusion is not feasible, give hydrocortisone 50 mg I.V. boluses every 6 hours.
Postoperative regimen: Continuous infusion of hydrocortisone 200 mg over 24 h while the patient is nil by mouth. If a continuous infusion is not feasible, give hydrocortisone 50 mg I.V. boluses every 6 hours. If the post-operative period is uncomplicated and once the patient can eat, resume oral glucocorticoids at an increased dose for 48 h (e.g., hydrocortisone 40 mg/daily in three divided doses; prednisone 10 mg/daily in one or two divided doses; dexamethasone 1 mg once daily) and then resume the pre-surgical dose. In case of post-operative complications (e.g., significant pain, infections), maintain an increased oral dose or give stress-dose glucocorticoids I.V. as clinically appropriate.

Labor and vaginal delivery

Table 8:

Open in new tab

Suggested glucocorticoid regimens in patients at risk of or with diagnosed glucocorticoid-induced adrenal insufficiency during exposure to stress

	General considerations	Examples	Suggested regimen
Minor stress	If the patient is already taking hydrocortisone ≥40 mg daily prednisone ≥10 mg daily, or dexamethasone ≥1 mg daily, there is typically no need to increase the dose unless there are signs of hemodynamic instability.	Illness requiring bed rest Illness with fever (out of hospital) Illness requiring treatment with antibiotics (out of hospital) Significant emotional stress (e.g., bereavement)	If not on daily glucocorticoids: give hydrocortisone 40 mg total daily dose, to be given in three divided doses (e.g., 20 mg on rising, 10 mg 12 midday, 10 mg 5pm). Continue for 2-5 days until well (or for the duration of antibiotic treatment). If on hydrocortisone <40 mg total daily dose: increase to 40 mg total daily dose, to be given in three divided doses (e.g., 20 mg on rising, 10 mg 12 midday, 10 mg 5pm). Continue for 2-5 days until well (or for the duration of antibiotic treatment). If on prednisone <10 mg total daily dose: increase to 10 mg total daily dose, to be given in one or two divided doses. Continue for 2-5 days until well (or for the duration of antibiotic treatment). If on dexamethasone <1 mg total daily dose: increase to 1 mg once daily. Continue for 2-5 days until well.
		Minor surgery including any procedure requiring local anesthesia	If not on daily glucocorticoids: give oral hydrocortisone 40 mg total daily dose, to be given in three divided doses (e.g., 20 mg one hour prior to the procedure, 10 mg six hours after the procedure, 10 mg after a further six hours). Continue glucocorticoids in patients who remain unwell after the procedure until clinically stable. If on hydrocortisone <40 mg total daily dose: increase to 40 mg total daily dose, to be given in three divided doses (e.g., 20 mg one hour prior to the procedure, 10 mg six hours after the procedure, 10 mg after a further six hours). Continue increased dose in patients who remain unwell after the procedure until clinically stable. If on prednisone <10 mg total daily dose: increase to 10 mg total daily dose, to be given one hour prior to the procedure. Continue increased dose in patients who remain unwell after the procedure until clinically stable. If on dexamethasone <1 mg total daily dose: increase to 1 mg total daily dose, to be given one hour prior to the procedure. Continue increased dose in patients who remain unwell after the procedure until clinically stable.
		Bowel procedures not carried out under general anesthesia	If not on daily glucocorticoids: give hydrocortisone 20 mg total daily dose, to be given in three divided doses (e.g., 10 mg one hour prior to the procedure, 5 mg six hours after the procedure, 5 mg after a further six hours). If on daily glucocorticoids: continue normal glucocorticoid dose. Give an equivalent I.V. dose if prolonged nil by mouth.
Moderate and major stress	If the patient is already taking hydrocortisone ≥200 mg daily, prednisone ≥50 mg daily, or dexamethasone ≥6-8 mg daily, there is typically no need to increase the dose In patients with suspected reduced absorption (persistent vomiting or diarrhea), nil by mouth, or unable to take tablets, give stress-dose glucocorticoids I.V. or I.M. High body weight can be taken into consideration as a factor indicating higher dosage requirements.	Severe intercurrent illness, for example: Persistent vomiting or diarrhea from gastro-intestinal illness. Infection requiring hospital admission or I.V. antibiotics (e.g., sepsis). Acute trauma resulting in significant blood loss or hospital admission.	For patients with persistent vomiting or diarrhea who are well enough to remain out of hospital: Hydrocortisone 100 mg I.M. injection immediately, which can be repeated after 6 hours if needed. If symptoms do not resolve or hemodynamic instability develops, admit to hospital for I.V. urgent glucocorticoid and fluid administration. Patients requiring hospital admission: Hydrocortisone 100 mg I.V. bolus or I.M. injection immediately, followed by immediate initiation of a continuous infusion of hydrocortisone 200 mg over 24 h. If a continuous infusion is not feasible, give hydrocortisone 50 mg I.V. boluses every 6 hours. The duration and dose of the glucocorticoid regimen thereafter must be individualized based on the stressor type and the patient’s clinical status.
		Surgery or any procedure requiring general or regional anesthesia with anticipated short recovery time and no nil by mouth	Intra-operative regimen: Hydrocortisone 100 mg I.V. bolus at induction, followed by immediate initiation of a continuous infusion of hydrocortisone 200 mg over 24 h. If a continuous infusion is not feasible, give hydrocortisone 50 mg I.V. boluses every 6 hours. Postoperative regimen: Resume oral glucocorticoids at an increased dose for 48 h (e.g., hydrocortisone 40 mg/daily in three divided doses; prednisone 10 mg/daily in one or two divided doses; dexamethasone 1 mg once daily) and then resume the pre-surgical dose. In case of post-operative complications (e.g., significant pain, infections), maintain an increased oral dose or give stress-dose glucocorticoids I.V. as clinically appropriate.
		Surgery (including cesarean section) or any procedure requiring general or regional anesthesia with nil by mouth or expected long recovery time	Intra-operative regimen: Hydrocortisone 100 mg I.V. bolus at induction, followed by immediate initiation of a continuous infusion of hydrocortisone 200 mg over 24 h. If a continuous infusion is not feasible, give hydrocortisone 50 mg I.V. boluses every 6 hours. Postoperative regimen: Continuous infusion of hydrocortisone 200 mg over 24 h while the patient is nil by mouth. If a continuous infusion is not feasible, give hydrocortisone 50 mg I.V. boluses every 6 hours. If the post-operative period is uncomplicated and once the patient can eat, resume oral glucocorticoids at an increased dose for 48 h (e.g., hydrocortisone 40 mg/daily in three divided doses; prednisone 10 mg/daily in one or two divided doses; dexamethasone 1 mg once daily) and then resume the pre-surgical dose. In case of post-operative complications (e.g., significant pain, infections), maintain an increased oral dose or give stress-dose glucocorticoids I.V. as clinically appropriate.
		Labor and vaginal delivery	Hydrocortisone 100 mg I.V. bolus at onset of labor, followed by immediate initiation of a continuous infusion of hydrocortisone 200 mg over 24 h. If a continuous infusion is not feasible, give hydrocortisone 50 mg I.V. boluses every 6 hours.

	General considerations	Examples	Suggested regimen
Minor stress	If the patient is already taking hydrocortisone ≥40 mg daily prednisone ≥10 mg daily, or dexamethasone ≥1 mg daily, there is typically no need to increase the dose unless there are signs of hemodynamic instability.	Illness requiring bed rest Illness with fever (out of hospital) Illness requiring treatment with antibiotics (out of hospital) Significant emotional stress (e.g., bereavement)	If not on daily glucocorticoids: give hydrocortisone 40 mg total daily dose, to be given in three divided doses (e.g., 20 mg on rising, 10 mg 12 midday, 10 mg 5pm). Continue for 2-5 days until well (or for the duration of antibiotic treatment). If on hydrocortisone <40 mg total daily dose: increase to 40 mg total daily dose, to be given in three divided doses (e.g., 20 mg on rising, 10 mg 12 midday, 10 mg 5pm). Continue for 2-5 days until well (or for the duration of antibiotic treatment). If on prednisone <10 mg total daily dose: increase to 10 mg total daily dose, to be given in one or two divided doses. Continue for 2-5 days until well (or for the duration of antibiotic treatment). If on dexamethasone <1 mg total daily dose: increase to 1 mg once daily. Continue for 2-5 days until well.
		Minor surgery including any procedure requiring local anesthesia	If not on daily glucocorticoids: give oral hydrocortisone 40 mg total daily dose, to be given in three divided doses (e.g., 20 mg one hour prior to the procedure, 10 mg six hours after the procedure, 10 mg after a further six hours). Continue glucocorticoids in patients who remain unwell after the procedure until clinically stable. If on hydrocortisone <40 mg total daily dose: increase to 40 mg total daily dose, to be given in three divided doses (e.g., 20 mg one hour prior to the procedure, 10 mg six hours after the procedure, 10 mg after a further six hours). Continue increased dose in patients who remain unwell after the procedure until clinically stable. If on prednisone <10 mg total daily dose: increase to 10 mg total daily dose, to be given one hour prior to the procedure. Continue increased dose in patients who remain unwell after the procedure until clinically stable. If on dexamethasone <1 mg total daily dose: increase to 1 mg total daily dose, to be given one hour prior to the procedure. Continue increased dose in patients who remain unwell after the procedure until clinically stable.
		Bowel procedures not carried out under general anesthesia	If not on daily glucocorticoids: give hydrocortisone 20 mg total daily dose, to be given in three divided doses (e.g., 10 mg one hour prior to the procedure, 5 mg six hours after the procedure, 5 mg after a further six hours). If on daily glucocorticoids: continue normal glucocorticoid dose. Give an equivalent I.V. dose if prolonged nil by mouth.
Moderate and major stress	If the patient is already taking hydrocortisone ≥200 mg daily, prednisone ≥50 mg daily, or dexamethasone ≥6-8 mg daily, there is typically no need to increase the dose In patients with suspected reduced absorption (persistent vomiting or diarrhea), nil by mouth, or unable to take tablets, give stress-dose glucocorticoids I.V. or I.M. High body weight can be taken into consideration as a factor indicating higher dosage requirements.	Severe intercurrent illness, for example: Persistent vomiting or diarrhea from gastro-intestinal illness. Infection requiring hospital admission or I.V. antibiotics (e.g., sepsis). Acute trauma resulting in significant blood loss or hospital admission.	For patients with persistent vomiting or diarrhea who are well enough to remain out of hospital: Hydrocortisone 100 mg I.M. injection immediately, which can be repeated after 6 hours if needed. If symptoms do not resolve or hemodynamic instability develops, admit to hospital for I.V. urgent glucocorticoid and fluid administration. Patients requiring hospital admission: Hydrocortisone 100 mg I.V. bolus or I.M. injection immediately, followed by immediate initiation of a continuous infusion of hydrocortisone 200 mg over 24 h. If a continuous infusion is not feasible, give hydrocortisone 50 mg I.V. boluses every 6 hours. The duration and dose of the glucocorticoid regimen thereafter must be individualized based on the stressor type and the patient’s clinical status.
		Surgery or any procedure requiring general or regional anesthesia with anticipated short recovery time and no nil by mouth	Intra-operative regimen: Hydrocortisone 100 mg I.V. bolus at induction, followed by immediate initiation of a continuous infusion of hydrocortisone 200 mg over 24 h. If a continuous infusion is not feasible, give hydrocortisone 50 mg I.V. boluses every 6 hours. Postoperative regimen: Resume oral glucocorticoids at an increased dose for 48 h (e.g., hydrocortisone 40 mg/daily in three divided doses; prednisone 10 mg/daily in one or two divided doses; dexamethasone 1 mg once daily) and then resume the pre-surgical dose. In case of post-operative complications (e.g., significant pain, infections), maintain an increased oral dose or give stress-dose glucocorticoids I.V. as clinically appropriate.
		Surgery (including cesarean section) or any procedure requiring general or regional anesthesia with nil by mouth or expected long recovery time	Intra-operative regimen: Hydrocortisone 100 mg I.V. bolus at induction, followed by immediate initiation of a continuous infusion of hydrocortisone 200 mg over 24 h. If a continuous infusion is not feasible, give hydrocortisone 50 mg I.V. boluses every 6 hours. Postoperative regimen: Continuous infusion of hydrocortisone 200 mg over 24 h while the patient is nil by mouth. If a continuous infusion is not feasible, give hydrocortisone 50 mg I.V. boluses every 6 hours. If the post-operative period is uncomplicated and once the patient can eat, resume oral glucocorticoids at an increased dose for 48 h (e.g., hydrocortisone 40 mg/daily in three divided doses; prednisone 10 mg/daily in one or two divided doses; dexamethasone 1 mg once daily) and then resume the pre-surgical dose. In case of post-operative complications (e.g., significant pain, infections), maintain an increased oral dose or give stress-dose glucocorticoids I.V. as clinically appropriate.
		Labor and vaginal delivery	Hydrocortisone 100 mg I.V. bolus at onset of labor, followed by immediate initiation of a continuous infusion of hydrocortisone 200 mg over 24 h. If a continuous infusion is not feasible, give hydrocortisone 50 mg I.V. boluses every 6 hours.

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