What are the landmark trials regarding stress-dose corticosteroids (steroids)?

From the Guidelines

The use of stress dose steroids in patients on chronic steroid therapy is still a topic of debate, but the most recent and highest quality study suggests that perioperative stress-dose steroid administration may not be necessary in all cases, and a more individualized approach should be taken. According to the 2021 guidelines published in the World Journal of Emergency Surgery 1, the administration of stress-dose steroids should be based on the patient's perioperative condition and surgical risk, rather than a blanket approach. The study by Zaghiyan et al. mentioned in the guidelines found no differences in postural hypotension or adrenal insufficiency between patients receiving high-dose glucocorticoids and those receiving low-dose glucocorticoids 1. Some key points to consider when deciding on stress dose steroids include:

• The patient's daily glucocorticoid dose, with a dose equivalent to prednisolone ≥ 5 mg for longer than 1 month considered an adrenal suppressive dose 1
• The degree of physiological stress, with major surgery considered a significant stressor 1
• The patient's overall health and stability, with a low threshold for administration of a rescue dose of steroids in the event of unexplained intra- or postoperative hypotension 1 The 2017 American College of Rheumatology guideline for the perioperative management of antirheumatic medication in patients with rheumatic diseases undergoing elective total hip or total knee arthroplasty also suggests continuing the current daily dose of glucocorticoids rather than administering perioperative supra-physiologic glucocorticoid doses 1. Overall, the decision to use stress dose steroids should be made on a case-by-case basis, taking into account the individual patient's needs and risk factors. Some of the key benefits of stress dose steroids include:
• Prevention of adrenal crisis in patients with hypothalamic-pituitary-adrenal axis suppression
• Reduction of hemodynamic instability and hypotension
• Potential reduction of infection risk However, the risks and benefits of stress dose steroids must be carefully weighed, and the decision to use them should be based on the most recent and highest quality evidence available. In terms of specific dosing, the guidelines suggest using hydrocortisone 100mg IV before anesthesia induction, followed by 50mg every 6 hours for 24 hours in patients on chronic steroid therapy 1. Ultimately, the use of stress dose steroids should be individualized and based on the patient's specific needs and risk factors, rather than a one-size-fits-all approach.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Landmark Trials on Stress Dose Steroids

• There are several studies that discuss the management of adrenal insufficiency during stress, including medical illness and surgery 2.
• The use of stress dose steroids in patients with adrenal insufficiency is a topic of ongoing debate, with some studies suggesting that high doses and long duration of glucocorticoid coverage may not be necessary 2.
• A review of the literature on adrenal function and dysfunction in critically ill patients highlights the complexity of diagnosing and treating critical-illness-related corticosteroid insufficiency (CIRCI) 3.
• Recent studies have challenged the concept of CIRCI and the use of large stress doses of hydrocortisone to treat it, citing conflicting results from randomized clinical trials 3.

Management of Adrenal Insufficiency

• The management of adrenal insufficiency during stress requires individualized treatment plans, taking into account the patient's specific needs and medical history 4, 5.
• The use of glucocorticoid replacement therapy is essential for patients with adrenal insufficiency, but the optimal dose and duration of treatment are not well established 4, 5.
• A review of therapy options for adrenal insufficiency highlights the importance of stress adaptation to prevent adrenal crises, as well as the need for life-long glucocorticoid substitution therapy 6.

Stress Dose Steroids in Clinical Practice

• The indication for adding stress doses of glucocorticoid during ongoing glucocorticoid treatment remains unclear, and more research is needed to establish clear guidelines 5.
• Clinical judgment is essential in managing patients with adrenal insufficiency during stress, and treatment plans should be tailored to the individual patient's needs 2.
• Education and awareness of clinicians and patients are crucial in improving the management of adrenal insufficiency and preventing adrenal crises 5, 6.