Perioperative steroid stress dosing: what’s current

The 300 mg/day regimen came from 1950s case reports about stopping steroids, not from trials about escalating them.

Reviewed and updated August 2026 · Written by Anastasia Jackson, DNAP, CRNA

Every clinical claim on this page is cited to its source below. How we source clinical content — including the corrections we have made and why.

Two questions get conflated here, and separating them answers almost everything: does this patient have adrenal insufficiency, or do they merely take steroids? The answer determines whether they need a stress dose or simply need their usual dose not to be interrupted.

Step 1: which patient is this?

Step 2: is the axis likely suppressed?

The threshold: daily doses of prednisolone of 5 mg or greater in adults — or 10–15 mg/m² hydrocortisone equivalent in children — may result in HPA axis suppression if given for one month or more, by oral, inhaled, intranasal, intra-articular or topical route.¹ Inhaled and topical routes are the ones most often overlooked in a medication history.

Equivalence, for converting the home dose

5 mg prednisolone ≈ 15–20 mg hydrocortisone ≈ 4 mg methylprednisolone ≈ 0.5 mg dexamethasone.⁵ Duration of action and mineralocorticoid activity differ, so these are approximations for dose-equivalence rather than interchangeable substitutions — and published equivalence tables differ from each other, the dexamethasone figure most of all, which is quoted elsewhere as 0.75 mg. Use your institution’s table rather than treating any single one as authoritative.

Step 3: the numbers

Diagnosed adrenal insufficiency

UK guidance from the Association of Anaesthetists, the Royal College of Physicians and the Society for Endocrinology:¹

• Hydrocortisone 100 mg IV at induction, in adults with adrenal insufficiency from any cause.
• Followed by a continuous infusion of 200 mg per 24 hours, continued until the patient is eating and drinking.
• Infusion is preferred to intermittent boluses where IV access allows — 200 mg/24 h by infusion rather than 50–100 mg every 6 hours.⁵
• Fludrocortisone is not usually needed while on parenteral hydrocortisone, which supplies sufficient mineralocorticoid activity.⁵
• Obstetric: hydrocortisone 100 mg at the onset of labor, then 200 mg/24 h by infusion or 50 mg IM every 6 hours until after delivery.¹

Glucocorticoid-induced suppression

Continue the usual daily dose. Because oral intake is unreliable in the early postoperative period, giving the daily glucocorticoid plus a short course of IV hydrocortisone 25 to 100 mg per day, scaled to surgical stress, is reasonable.²

If your institution uses the older tiered regimen, it looks like this:⁶

• Minor (inguinal hernia under local): no supplement; continue normal dosing.
• Moderate (joint replacement, lower extremity revascularization): hydrocortisone 50 mg IV, then 25 mg every 8 hours for 24 hours; resume usual dose.
• Major (open heart, esophagogastrectomy, proctocolectomy): hydrocortisone 100 mg IV, then 50 mg every 8 hours for 24 hours, halving daily to maintenance.

Why the doses came down

What the evidence has since shown:

• Marik and Varon, systematic review: patients on therapeutic doses of corticosteroids undergoing surgery do not routinely require stress doses so long as they continue to receive their usual daily dose. Patients on physiologic replacement for primary HPA disease do.⁸
• An RCT of 17 patients on prednisone 5–60 mg/day, all with abnormal cosyntropin stimulation tests, randomized to saline versus 200 mg hydrocortisone tapered over 3 days while continuing their usual dose: no adrenal crisis in the daily-dose-plus-placebo group.²
• A randomized trial in major colorectal surgery found no difference in postural hypotension or adrenal insufficiency between high-dose hydrocortisone (100 mg IV three times daily) and low-dose (the equivalent of the preoperative dose given IV).⁷
• The Cochrane review was withdrawn in 2012 because the evidence base was very poor and limited in size and quality.¹

On testing

Adrenal function testing is not required in patients on therapeutic doses, because the test is overly sensitive and does not predict which patient will develop an adrenal crisis.⁸ Correlation between biochemical testing for adrenal insufficiency and clinical events is lacking.² A patient with an abnormal stimulation test who sails through surgery is the common case, not the exception.

Practical points

• Ask about route, not just drug. Inhaled, intranasal, topical and intra-articular steroids all suppress the axis at sufficient dose and duration.¹
• Do not fast a child with adrenal insufficiency more than 6 hours, and check blood glucose hourly after surgery until enteral intake resumes.¹
• Hyponatremia postoperatively may indicate inadequate glucocorticoid replacement rather than a fluid problem.⁵
• Blanket recommendations are not appropriate — the guideline says so itself, and asks for a pragmatic approach given the state of the evidence.¹

Frequently asked questions

Do I need stress dose steroids before surgery?

It depends which situation you are in. Patients with diagnosed primary or secondary adrenal insufficiency are at significant risk of adrenal crisis and must receive stress-dose hydrocortisone.¹ Patients whose axis is suppressed by long-term steroid treatment for another condition generally do not need a stress dose, provided their usual daily dose is continued.^2,8

What is the hydrocortisone dose for major surgery in adrenal insufficiency?

UK guidance: hydrocortisone 100 mg IV at induction, followed by a continuous infusion of 200 mg per 24 hours until the patient is eating and drinking.¹ Infusion is preferred over intermittent 50–100 mg boluses every 6 hours where access allows.⁵

How much prednisone suppresses the HPA axis?

Daily doses of prednisolone of 5 mg or more in adults, or 10–15 mg/m² hydrocortisone equivalent in children, may cause suppression if given for one month or more — by oral, inhaled, intranasal, intra-articular or topical route.¹ The non-oral routes are the ones most often missed in a medication history.

Where did the 300 mg hydrocortisone regimen come from?

From case reports in the 1950s of adrenal insufficiency after abrupt preoperative withdrawal of glucocorticoids.⁷ It was never derived from trials, and subsequent randomized and observational data have not supported it. The Cochrane review on the question was withdrawn in 2012 because the evidence base was too poor.¹

Should adrenal function be tested before surgery?

Not routinely in patients on therapeutic steroid doses. The test is overly sensitive and does not predict who will develop an adrenal crisis,⁸ and correlation between biochemical testing and clinical events is lacking.² Testing may be worth doing in patients on 5–20 mg/day for three weeks or longer, where suppression status is genuinely unknown and time permits.³

What if the patient recently stopped steroids?

Treat as potentially suppressed for 3 to 6 months after the last dose, since full recovery of the hypothalamic-pituitary-adrenal axis takes that long.⁴ Careful assessment of the axis is recommended in patients who stopped steroid therapy before surgery.²

References

1. Woodcock T, Barker P, Daniel S, et al. Guidelines for the management of glucocorticoids during the peri-operative period for patients with adrenal insufficiency: guidelines from the Association of Anaesthetists, the Royal College of Physicians and the Society for Endocrinology UK. Anaesthesia. 2020;75(5):654–663. doi:10.1111/anae.14963. PMID 32017012.
2. Chen Cardenas SM, Santhanam P, Morris-Wiseman L, Salvatori R, Hamrahian AH. Perioperative evaluation and management of patients on glucocorticoids. J Endocr Soc. 2022;7(2):bvac185. doi:10.1210/jendso/bvac185. PMID 36545644.
3. Adrenal insufficiency and perioperative corticosteroids. OpenAnesthesia, accessed 2024. Summarizes the dose and duration thresholds and the HPA testing recommendation.
4. Perioperative stress dose guidelines. Stanford Department of Pediatric Anesthesia. Notes that full HPA axis recovery takes 3–6 months after the last steroid dose.
5. Peri-operative guidance for patients with or at risk of adrenal insufficiency. NHS Highland adult therapeutic guidelines, Right Decisions. Equivalence table, infusion-versus-bolus preference, fludrocortisone guidance, hyponatraemia note.
6. Emergency corticosteroid supplementation in patients taking exogenous corticosteroids — the tiered minor/moderate/major regimen, as summarized from Chilkoti GT, Singh A, Mohta M, Saxena AK (2019).
7. The management of the surgical patient taking glucocorticoids. UpToDate. Describes the historic 300 mg/day practice and its 1950s origin, and summarizes the randomized trial in major colorectal surgery comparing high- and low-dose regimens.
8. Marik PE, Varon J. Requirement of perioperative stress doses of corticosteroids: a systematic review of the literature. Arch Surg. 2008;143(12):1222–1226. PMID 19075176.