Steroid Stress Dosing and Weaning Clinical Pathway – Chronic GC Therapy with Prednisone

Steroid Stress Dosing and Weaning Clinical Pathway

Chronic Glucocorticoid Therapy with Prednisone/Prednisolone/Methylprednisolone

Emergency/Critical Bolus Dose for Severe Stress
  • If a calculated BSA is available, the emergent first dose should be hydrocortisone based on BSA.
  • If a calculated BSA is unavailable, the emergent first dose should be hydrocortisone based on age.
  • Stress dosing regimens to be initiated after the hydrocortisone severe stress bolus dose are provided in the Stress Dosing Regimen table below.
Severe
Stress		 Hydrocortisone dose by BSA
IV, IM		 100 mg/m2
Max dose 100 mg
Hydrocortisone dose by age
IV, IM		 Age 0-24 mos 25 mg
Age 25 mos-10 yrs 50 mg
Age > 10 yrs 100 mg
Moderate
Stress		 No emergent bolus dose necessary, proceed to section below
Stress Dosing Regimens for Moderate and Severe Stress:
Chronic Glucocorticoid Therapy with Prednisone/Prednisolone/Methylprednisolone
  • Stress dosing regimen is based on the child’s current maintenance dose and degree of stress.
  • Severe stress dosing will be in the inpatient setting only.
  Current
Maintenance Dose		 Home Dose Stress Dosing Regimen
Severe Stress < 20 mg/m2/day
for BSA < 2 m2
or
< 40 mg/day
for BSA ≥ 2 m2		 Hold
  • Begin 6 hrs after hydrocortisone stress dose
  • Start IV methylprednisolone 10 mg/m2/dose IV every 12 hrs, up to 20 mg/dose
≥ 20 mg/m2/day
for BSA < 2 m2
or
≥ 40 mg/day
for BSA ≥ 2 m2		 Continue
  • Begin 6 hrs after hydrocortisone stress dose
  • Convert total daily prednisone/prednisolone dose to IV methylprednisolone at 1:1 ratio and divide every 12 hrs*
Moderate Stress < 10 mg/m2/day
for BSA < 2 m2
or
< 20 mg/day
for BSA ≥ 2 m2		 Hold
  • Begin 12 hrs after the last tolerated home dose
    • Increase prednisone/prednisolone dose to 5 mg/m2/dose PO every 12 hrs, up to 10 mg/dose
    • If IV steroids necessary, use IV methylprednisolone 5 mg/m2/dose IV every 12 hrs, up to 10 mg/dose*
≥ 10 mg/m2/day
for BSA < 2 m2
or
≥ 20 mg/day
for BSA ≥ 2 m2		 Continue
  • Begin 12 hrs after the last tolerated home dose
    • Continue prednisone/prednisolone total daily dose but divide every 12 hrs
    • If IV steroids necessary, convert total daily dose to IV methylprednisolone at 1:1 ratio and divide every 12 hrs*

* Technical conversion from prednisone/prednisolone to methylprednisolone is 1.25:1 ratio; however, in clinical practice we utilize a 1:1 ratio for ease of conversion and have not witnessed adverse effects.