Glucocorticoid Replacement Therapy in Special Situation

Patient Considerations

Preexisting adrenal insufficiency
Patients with a history of exogenous glucocorticoid use presenting with "cushingoid appearance" or "adrenal crisis"
Possible glucocorticoid-induced adrnal insufficiency
a. Oral : > 3 weeks: Prednidsolone ≥ 5 mg/day, Hydrocortosone ≥ 30 mg/day, Dexamethasone ≥ 0.75 mg/day
b. Inhaled glucocorticoids: High dose > 6-12 months
- Fluticasone propionate > 500 μg/day, Beclomethasone dipropionate > 1000 μg/day (standard) or > 400 μg/day (extradine), Budesonide > 800 μg/day, Ciclesonide > 320 μg/day, Fluticasone furoate > 100 μg/day, Mometasone furoate > 400 μ/day
Intra-articular: Repeated injection < 3 months
Any steroid with strong CYP450 3A4 inhibitors

- clarithromycin, telithromycin

- itraconazole, ketoconazole, voriconazole, posaconazole

- ceritinib, idelalisib

- boceprevir, telaprevir

- lopinavir, darunavir, ritonavir, cobisistat

- mifepristone, nefazodone

Stress and Sepsis

Minor stress

- Illness requiring bed rest

- Outpatients with fever (T>38°C)

-Outpatients requiring treatment with antibiotics

- Significant emotional stress (e.g., bereavement)

-Increase prednisolone to 10 mg/day

or continue at the previous dose if ≥ 10 mg/day

-Continue for 2-5 days until doing well or for

the same duration as the antibiotic treatment

Moderate stress

Unable to tolerate oral therapy:

- Gastroparesis

- NPO (any cause)

- Infection requiring hospital admission or IV antibiotics (e.g., sepsis)

-Increase prednisolone to 15 mg/day or Hydrocortisone 100 mg IM or SC OD

(which can be repeated after 6 hours if needed)

Severe stress

Acute trauma resulting in significant blood loss

or hospital admission

- Hydrocortisone 100 mg IV/IM bolus then 200 mg IV over 24 hours or

- Hydrocortisone 50 mg IV bolus every 6 hours

Septic shock

Not responsive to fluid and requiring moderate to high dose of vasopressor

(> 0.1µg/kg/min of NE or equivalent)

- Hydrocortisone 100 mg IV.IM bolus then 200 IV over 24 hours

For Pre-existing AI: taper dose rapidly decrease by half dose to maintenance level

For CIRCI: continue full dose for 5-7days

Pre-operation

Minor surgery

Any procedure requiring local anesthesia

- Increase prednisolone to 10 mg/day or

continue at the previous dose if ≥ 10 mg/day

- Given one hour prior to the procedure

- Continue increased dose in patients who remain unwell after the procedure until clinically stable

Bowel procedures not carried out under general anesthesia

- Continue glucocorticoid dose as previously

- Given and equivalent IV dose if prolonged NPO

Moderate surgery

Barium enema, endoscopy, arteriography

- Hydrocortisone 100 mg IM or SC OD

Major surgery

- General anesthesia, trauma, delivery disease requires intensive care

- Surgery or any procedure requiring general or regional anesthesia with NPO

- Hydrocortisone 100 IV before induction of anesthesia and continue every 8 hours for first 24 hours or Hydrocortisone 100 mg IV then 200 mg continue in 24 hours

-Taper dose rapidly, decrease by half dose per day to maintainance level

References

Adapt form

1. Felix Beuschlein, Tobias Else, Irina Bancos, Stefanie Hahner, Oksana Hamidi, Leonie van Hulsteijn, Eystein S Husebye, Niki Karavitaki, Alessandro Prete, Anand Vaidya, Christine Yedinak, Olaf M Dekkers, European Society of Endocrinology and Endocrine Society Joint Clinical Guideline: Diagnosis and Therapy of Glucocorticoid-induced Adrenal Insufficiency, The Journal of Clinical Endocrinology & Metabolism, Volume 109, Issue 7, July 2024, Pages 1657–1683

2. Prete, A. & Bancos, I. Glucocorticoid induced adrenal insufficiency. BMJ 374, n1380 (2021).

3. Chaudhuri D, Nei AM, Rochwerg B, Balk RA, Asehnoune K, Cadena R, Carcillo JA, Correa R, Drover K, Esper AM, Gershengorn HB, Hammond NE, Jayaprakash N, Menon K, Nazer L, Pitre T, Qasim ZA, Russell JA, Santos AP, Sarwal A, Spencer-Segal J, Tilouche N, Annane D, Pastores SM. 2024 Focused Update: Guidelines on Use of Corticosteroids in Sepsis, Acute Respiratory Distress Syndrome, and Community-Acquired Pneumonia. Crit Care Med. 2024 May 1;52(5):e219-e233.

4. Borresen SW, Klose M, Glintborg D, Watt T, Andersen MS, Feldt-Rasmussen U. Approach to the Patient With Glucocorticoid-induced Adrenal Insufficiency. J Clin Endocrinol Metab. 2022 Jun 16;107(7):2065-2076.