Steroid Stress Dosing and Weaning Clinical Pathway – Dosing Recommendations

Steroid Stress Dosing and Weaning Clinical Pathway – Dosing Recommendations

Stress Dose Steroid Recommendations: Key Concepts

Key concepts to consider when prescribing stress dose steroids include:

See Steroid Potency, Physiologic Dosing

  • Stress dosing required for the following:
    • Currently receiving chronic glucocorticoid therapy ≥ 2 wks.
    • Previously on chronic glucocorticoid therapy ≥ 2 wks and have had steroids discontinued, but normal HPA axis function has not been documented since discontinuation.
  • If child is receiving a daily steroid dose, stress doses should never be less than child’s
    maintenance dose.
  • Stress doses can be switched from intravenous to oral if tolerated.
  • Specific recommendations for stress dosing, including emergent injectable hydrocortisone (Solu-Cortef), should be documented in the problem list by the team prescribing chronic steroid therapy under the diagnostic code for secondary adrenal insufficiency (ICD-10: E27.40)
    • Note that children with primary adrenal insufficiency should be entered under diagnostic
      code ICD-10: E27.1
  • Stress dose steroid recommendations are based on the individual corticosteroid utilized at baseline.
  • Emergency/critical bolus dose for severe stress is indicated for all patients who meet the chronic glucocorticoid therapy definition experiencing severe stress.
Emergency/Critical Bolus Dose for Severe Stress

Use hydrocortisone for all patients, regardless of chronic glucocorticoid agent.

  • For Severe Stress
Severe Stress Hydrocortisone Dose by BSA
IV, IM		 100 mg/m2/dose
Max dose 100 mg
Hydrocortisone Dose by Age
IV, IM		 Age 0-24 mos 25 mg
Age 25 mos to 10 yrs 50 mg
Age > 10 yrs 100 mg
Moderate Stress No emergent stress bolus dose necessary.
Use specific stress dosing regimen.