Adrenal insufficiency and stress-dose steroids
Why examiners ask this
Steroids appear in a large fraction of stems as a single line in the medication list, and the examiner wants to know whether you noticed it, whether you can say who needs supplementation and how much, and whether you recognize refractory hypotension as adrenal crisis rather than reaching for a fourth vasopressor. It tests application of knowledge, because the thresholds for "at risk" have fallen and the dosing has been standardized, and judgment, because over-supplementing carries its own cost.
The 60-second answer
My first question is whether this patient's axis may be suppressed. Current guidance treats a prednisone-equivalent dose above roughly 5 mg daily for three to four weeks or longer as putting the patient at risk, along with anyone with primary adrenal insufficiency or a Cushingoid appearance.1 Shorter courses carry low risk.1 For the at-risk patient I continue the home dose and give parenteral cover for any procedure under general or regional anesthesia;1 minor procedures under local anesthesia need only the oral dose. For intermediate and major surgery I give hydrocortisone 100 mg IV at induction followed by 200 mg over 24 hours, as an infusion or 50 mg every 6 hours, while the patient is nil by mouth, then double the oral dose for about 48 hours before returning to the home dose.2 Intraoperatively I watch for hypotension that fluid and vasopressors do not fix, and I treat that with hydrocortisone 100 mg before I have the cortisol result back.3
Decision points and the "why"
- Who is suppressed — the hypothalamic-pituitary-adrenal axis recovers slowly and unpredictably. High-dose inhaled or topical steroids, intra-articular injection within the past two months, several steroid formulations at once, or a strong CYP3A4 inhibitor (ritonavir, itraconazole) can all suppress the axis.1 When the history is unclear and the surgery is major, I give the stress dose rather than test, because the morning cortisol and cosyntropin test take time I do not have.
- Dose matched to stress — the 200 mg per 24 hours regimen is meant to approximate the cortisol output of a major operation;2 the older 300 mg regimens were never physiologic and raise glucose, infection and wound risks. Minor procedures under local anesthesia need only the home dose.
- Hydrocortisone, not dexamethasone — hydrocortisone has mineralocorticoid activity, which matters in primary disease where aldosterone is also missing. Above 50 mg daily of hydrocortisone no separate mineralocorticoid is needed, so I hold fludrocortisone until the dose comes down.4 Dexamethasone 6–8 mg IV is an accepted alternative that covers 24 hours when hydrocortisone is unavailable.2
- Etomidate — a single induction dose inhibits 11-beta-hydroxylase for 6–12 hours.5 I avoid it in a patient with known adrenal insufficiency or septic shock, and if I used it in a patient who then becomes hypotensive I give hydrocortisone rather than debate the literature.
- Primary versus secondary — primary disease (Addison's, bilateral hemorrhage, adrenalectomy) loses aldosterone as well, so I expect hyperkalemia, hyponatremia and volume depletion; secondary disease from pituitary failure or exogenous steroids keeps aldosterone, so electrolytes are near normal and the problem is cortisol alone.3 Fludrocortisone is not needed for glucocorticoid-induced insufficiency.1
- Continue steroids in the anticipated crisis — if the patient vomits, is NPO for days, or is in the ICU with sepsis, I convert oral prednisone to intravenous hydrocortisone at an equivalent or stress dose rather than letting them miss doses.
The complication they will inject
Two hours into a colectomy in a patient with rheumatoid arthritis on prednisone 15 mg, the pressure is 70/40 and has not responded to 2 L of crystalloid and phenylephrine 200 mcg boluses, with a heart rate of 115 and a normal end-tidal CO2. I treat the usual differential first and quickly: bleeding, anaphylaxis, tension pneumothorax, ischemia, and anesthetic depth. With nothing found, I give hydrocortisone 100 mg IV, because adrenal crisis presents as vasodilated, vasopressor-resistant shock and the drug is harmless if I am wrong. I draw a cortisol before the dose if a tube is already in my hand, but I do not wait for it.3 I start norepinephrine, send a glucose and potassium because hypoglycemia and hyperkalemia accompany crisis, and continue hydrocortisone 200 mg over 24 hours, as an infusion or 50 mg every 6 hours.3 The examiner then asks whether I would have cancelled the case had I seen the prednisone preoperatively; the answer is no, I would have given the stress dose and proceeded.
Pitfalls that cost points
- Missing the steroid in the medication list and only recognizing it when the examiner asks about refractory hypotension.
- Quoting a full major-surgery regimen for a cataract or a carpal tunnel release under local anesthesia.
- Ordering a cosyntropin test on the morning of surgery and delaying a case that needed only a supplement.
- Calling for a third vasopressor before considering cortisol.
- Forgetting that hydrocortisone in large doses also raises the glucose and that the diabetic on steroids needs tighter checks.
Rapid-why
Q: Why not give more than 200 mg of hydrocortisone a day? A: That dose already covers the stress response of major surgery; higher doses only add hyperglycemia and infection risk.
Q: Why does hypotension in adrenal crisis resist catecholamines? A: Cortisol maintains vascular responsiveness to catecholamines by upregulating adrenergic receptors; without it the vessels are deaf to the drug.
Q: When do I taper the stress dose? A: Once eating and stable, double the oral dose for about 48 hours after major surgery, then back to the home dose; no taper is needed for a single perioperative dose.2
Q: Which lab pattern tells me this is primary disease? A: Hyponatremia with hyperkalemia and a high ACTH; secondary disease has a low-to-normal ACTH and normal potassium.3
Numbers to know
| Item | Value |
|---|---|
| At-risk threshold | Prednisone-equivalent ≥5 mg/day for ≥4 weeks (ES/ESE: ~4–6 mg for ≥3–4 weeks)2 |
| Minor procedure, local anesthesia | Usual oral dose |
| Intermediate or major surgery | Hydrocortisone 100 mg IV at induction, then 200 mg/24 h (infusion or 50 mg every 6 h)2 |
| After surgery | Double the oral dose for 48 h, then usual dose2 |
| Suspected crisis | Hydrocortisone 100 mg IV, then 200 mg/24 h3 |
| Etomidate suppression | 6–12 h after a single dose5 |
Links
- Intraoperative hypotension: differential and management, Vasopressors and inotropes: choosing and titrating, Sepsis and septic shock, hyperkalemia, Transsphenoidal surgery and acromegaly (coming)
- Endocrine Society/ESE guideline on glucocorticoid-induced adrenal insufficiency (2024); Society for Endocrinology and Association of Anaesthetists guidance on perioperative glucocorticoid replacement (2020)
Sources
- 1.Diagnosis and Therapy of Glucocorticoid-Induced Adrenal Insufficiency (clinical practice guideline) · Endocrine Society / European Society of Endocrinology, 2024 · endocrine.orgR2.1 risk thresholds (prednisone ~4–6 mg/day for ≥3–4 weeks); R3.1 parenteral stress dosing for procedures under general or regional anesthesia; R2.12 no fludrocortisone.
- 2.Guidance for the prevention and emergency management of adult patients with adrenal insufficiency (Table 3, peri-operative regimens) · Society for Endocrinology (Clinical Medicine), 2020 · pmc.ncbi.nlm.nih.govApplies to prednisolone-equivalent ≥5 mg for ≥4 weeks; hydrocortisone 100 mg at induction then 200 mg/24 h.
- 3.Adrenal Crisis · StatPearls (NCBI Bookshelf) · ncbi.nlm.nih.gov
- 4.Peri-Operative Glucocorticoid Cover (patient information, based on UHB guideline CG1106) · University Hospitals Birmingham / Society for Endocrinology, 2021 · library.bioscientifica.comNo mineralocorticoid needed while hydrocortisone exceeds 50 mg/24 h.
- 5.Etomidate · StatPearls · statpearls.com
Facts on this page were checked against these sources on Oct 14, 2026. Guidelines change; confirm doses against current institutional protocols.