stressdosing

Stress dosing refers to the temporary adjustment of glucocorticoid replacement therapy to meet the body's increased cortisol demands during physiologic stress in people with adrenal insufficiency or those on long-term glucocorticoid treatment. It is used to prevent adrenal crisis when the body’s need for cortisol rises during illness, injury, surgery, or other significant stress.

Rationale and scope

Under stress, the body normally increases cortisol production. Individuals with adrenal insufficiency cannot mount this response, making them vulnerable to life-threatening hypotension, electrolyte disturbances, and shock. Stress dosing aims to mimic the natural cortisol rise and maintain hemodynamic stability and metabolic balance. The approach is individualized, depending on the person’s baseline therapy, the severity of the stress, and clinical judgment.

Management principles

For mild illness or minor physical stress, patients may be advised to increase their usual glucocorticoid dose temporarily (often by a factor of two to three) and to maintain hydration and oral intake. For moderate to severe stress (high fever, vomiting or diarrhea with dehydration, major surgery, or significant trauma), higher doses are typically required, and parenteral administration is often used initially. In many guidelines, an example regimen includes an initial high-dose hydrocortisone given intravenously or intramuscularly, followed by additional doses at regular intervals, then a transition back to the usual oral replacement once the patient can tolerate oral intake, with a gradual taper back to baseline over one to a few days. Dosing is highly individualized and must follow clinician guidance and local protocols. In children, stress dosing is particularly weight-based and carefully monitored.

Risks and precautions

Overuse can lead to hyperglycemia, hypertension, edema, and increased infection risk. Under-treatment can precipitate adrenal crisis. Patients should wear medical identification and have access to emergency care if symptoms worsen.

See also: Addison’s disease, glucocorticoid therapy, adrenal crisis.