Steroid Stress Dosing and Weaning Clinical Pathway – Duration

Steroid Stress Dosing and Weaning Clinical Pathway – Duration

Duration of Stress Dose Steroid Coverage and Indications for Weaning from Supraphysiologic Glucocorticoid (GC) Doses to Physiologic Replacement

GC < 4 wks
  • Return to chronic GC therapy dose 24 hrs after the end of the stressor
  • If child is not taking maintenance/chronic glucocorticoid therapy, stress dosing may be discontinued without requiring a daily physiologic dose
GC ≥ 4 wks See Weaning Indications/Dosing
Simple Procedure/
Moderate Stress
e.g., MRI with general anesthesia or sedation, PICC placement
  • Immediately prior to procedure, administer first stress dose as indicated in steroid dosing chart
    • e.g., hydrocortisone 50 mg/m2/dose x 1 max dose 100 mg
  • No additional doses are required unless child has signs or symptoms of adrenal insufficiency post-procedure
  • For moderate stress not related to a procedure, coverage with stress dose GC should continue 24 hours after the stressor is resolved
Invasive Procedures/
Severe Stress
Abdominal or open-heart surgery, neurosurgical procedure
  • Administer first stress dose as indicated in steroid dosing chart, then continue stress dosing for at least 24 hrs post-procedure
  • Weaning of stress dose glucocorticoids is based on clinical improvement
  • Consider reducing dose by 25-50% each day as tolerated
  • Once child is back to clinical baseline, stress dose glucocorticoids can be discontinued
  • If the child is on chronically prescribed daily GC, resume daily dose once stressor is removed and is clinically back to his baseline condition

Weaning Recommendations from Supraphysiologic Glucocorticoid (GC) Doses to Physiologic Replacement Doses

  • If child is on chronic daily steroids for an underlying disease, such as respiratory or inflammatory disorder, weaning down to physiologic GC doses depends the clinical status of the child. To wean from physiologic GC doses to off glucocorticoids, see table.
  • If a child is on chronic daily steroids for an underlying disease and requires additional stress dose coverage for an illness or procedure, stress dose glucocorticoids can be discontinued
    24 hours after the stress has resolved. The child can then resume chronically prescribed
    daily dose.
  • Discuss further wean and long-term steroid plan with prescribing service.

If child does not require maintenance/chronic steroids, then the need for wean below physiologic glucocorticoid doses depends on length of exposure to glucocorticoids.

< 4 wks There is no need for physiologic dose — stop steroids once stress resolves
> 4 wks