Steroid Stress Dosing and Weaning — Case Examples — Clinical Pathway: All Settings

Steroid Stress Dosing and Weaning Clinical Pathway

Case Examples

Interpreting Stress Level

Severe Stress A child with past history of inflammatory bowel disease and chronic steroid use in last 6 mos admitted to the ICU with hypotension and altered mental status requiring resuscitation and vasopressor support should receive severe stress dose steroids until 24 hrs after resolution of acute illness.
Moderate Stress An 11-year-old child taking 2.5 mg of prednisone twice daily for juvenile rheumatoid arthritis develops fever of 38.5°C with a sore throat should receive moderate stress doses
(e.g., prednisone 5 mg twice daily) until 24 hrs after the last fever.
When No Stress Dose is Needed
  • Mild cold symptoms such as:
    • Runny nose
    • Dry cough
    • Sore throat
  • Minor cuts and scrapes
  • Routine dental care
  • Headache
  • Note: Some patients with minor illnesses may report significant fatigue and can receive moderate stress dosing. However, adrenal crisis is unlikely if stress dosing is withheld.

Weaning Glucocorticoids

Case 1
  • An ex-27 wk infant now 6 mos of age with chronic lung disease who had been treated with varying doses of dexamethasone over a 6 wk period
  • Weight = 6kg; BSA=0.3 m2
  • The infant is currently receiving low-dose dexamethasone at 0.02 mg/kg/dose ND q12hr
  • The clinician would like to stop dexamethasone
    • Convert patient to a physiologic hydrocortisone physiologic dose — hydrocortisone 5 mg/m2/dose ND given twice daily at 08:00 and 16:00
      • 4 days later wean to hydrocortisone 4 mg/m2/dose
        ND given twice daily at 08:00 and 16:00
      • 4 days later wean to hydrocortisone 3 mg/m2/dose
        ND given twice daily at 08:00 and 16:00
      • 4 days later discontinue hydrocortisone
    • Doses do not have to be exact
    • May test the HPA axis (e.g., AM cortisol at 08:00) no earlier than 24 hrs after the discontinuation of hydrocortisone. If the HPA axis is not recovered, may retest every 3 mos thereafter until the axis recovers.
Case 2
  • A child with BSA of 1.5 m2 is treated with prednisone 20 mg/day (13.3 mg/m2/day) at baseline and requires stress dosing for severe stress
    • The child’s current maintenance steroids are less than the equivalent of what is needed for severe stress
      • Give hydrocortisone 100 mg IV severe stress bolus dose
      • Starting 6 hrs after the bolus, give IV methylprednisolone 15 mg (10 mg/m2/dose) IV q12hr
Case 3
  • Child with BSA of 2.2 m2 admitted for septic shock
  • Started on hydrocortisone 50 mg IV q6hr and remained on that dose for 12 days in the ICU, but is now clinically stable
  • They are able to take enteral medications at this time
    • Discontinue hydrocortisone
    • AM cortisol level to assess HPA axis is not indicated after steroid discontinuation given the duration of therapy