| name | enda-adjust-glucocorticoid-stress-illness |
| description | Suggests adjusting glucocorticoid dose according to severity of illness or magnitude of the stressor in patients with primary adrenal insufficiency. Use when patient with PAI has intercurrent illness, fever, or stress. |
Adjust Glucocorticoid Dose According to Severity of Illness or Magnitude of Stressor
STEP 1 — Gather Information
Assess for intercurrent illness, fever, inability to tolerate oral meds, upcoming surgery/trauma/delivery, or other stressors; record temperature, need for bedrest, antibiotics, vomiting, fasting, surgical type, and ability to retain oral medication.
STEP 2 — Rule In / Rule Out
Determine if stressor warrants glucocorticoid dose increase: fever ≥38°C, illness requiring bedrest/antibiotics, vomiting/trauma preventing oral intake, minor/moderate/major surgical stress, or delivery; if none, continue usual dose.
STEP 3 — Classify or Stratify
Classify stressor magnitude:
- Fever 38–38.9°C → double usual oral dose.
- Fever ≥39°C → triple usual oral dose.
- Unable to tolerate oral (vomiting, trauma, fasting for procedure) → give IM hydrocortisone (adult 100 mg, child 50 mg/m2, infant 25 mg) followed by continuous IV infusion 200 mg/24h (or 50 mg q6h).
- Minor/moderate surgical stress → hydrocortisone 25–75 mg/24h.
- Major surgery/trauma/delivery/ICU → hydrocortisone 100 mg IV bolus then continuous infusion 200 mg/24h.
STEP 4 — Decide
Administer the selected glucocorticoid regimen; if oral route possible, give divided doses with largest dose in morning; if parenteral, start with bolus then continuous infusion; reassess after 24h and taper to maintenance as clinical improvement occurs.
Clinical Guardrails / Mimics / Pitfalls
Do not delay stress dosing while awaiting diagnostic results; avoid dexamethasone for stress dosing due to lack of mineralocorticoid activity and risk of adrenal crisis; do not underdose in hypotension or shock; ensure fluid resuscitation with isotonic saline and dextrose; do not rely on ACTH or cortisol levels to adjust stress doses.
Concrete Clinical Example
A 45‑year‑old woman with PAI presents with fever 39.5°C and productive cough; she doubles her usual hydrocortisone dose (e.g., from 20 mg AM/10 mg noon to 40 mg AM/20 mg noon) and continues until afebrile 24h later, then tapers back to maintenance.
Source: Diagnosis and Treatment of Primary Adrenal Insufficiency, Endocrine Society, 2016, DOI: 10.1210/jc.2015-1710
