What steroid regimen is recommended for preoperative (pre-op) management in a patient with Systemic Lupus Erythematosus (SLE) who is already on steroid therapy?

From the Guidelines

For patients with systemic lupus erythematosus (SLE) who are already on chronic steroid therapy and scheduled for surgery, continuing their current daily dose of glucocorticoids rather than administering supraphysiologic doses of glucocorticoids on the day of surgery is conditionally recommended. This approach is based on the latest guidelines from the American College of Rheumatology and the American Association of Hip and Knee Surgeons, as outlined in the 2022 guideline for the perioperative management of antirheumatic medication in patients with rheumatic diseases undergoing elective total hip or total knee arthroplasty 1. The guideline suggests that for patients with RA, AS, PsA, or all SLE undergoing THA or TKA who are receiving glucocorticoids for their rheumatic condition, continuing their current daily dose of glucocorticoids is recommended, rather than administering perioperative supra-physiologic glucocorticoid doses.

The rationale behind this recommendation is to avoid the potential risks associated with supraphysiologic doses of glucocorticoids, such as increased infection risk and hemodynamic instability. The guideline notes that the cutoff for immunosuppression according to the Centers for Disease Control and Prevention is 20 mg/day of prednisone for at least 2 weeks, and that observational studies demonstrate an increase in infection risk following TJA for long-term users of glucocorticoids. Therefore, continuing the current daily dose of glucocorticoids is a more appropriate approach, as it minimizes the risk of infection and hemodynamic instability while still providing adequate glucocorticoid coverage for the patient's rheumatic condition.

It is essential to note that this recommendation is specific to patients with SLE who are already on chronic steroid therapy and are undergoing elective total hip or total knee arthroplasty. The decision to continue or modify glucocorticoid therapy should be made on a case-by-case basis, taking into account the individual patient's baseline steroid dose, the severity of their SLE, and the complexity of the surgical procedure. Coordination between the rheumatologist, anesthesiologist, and surgeon is crucial to optimize perioperative management and minimize the risk of complications.

Some may argue that perioperative stress-dose steroids are necessary for patients with SLE on chronic steroid therapy, however, the latest evidence from 1 and 1 suggests that this may not be the case, and that continuing the current daily dose of glucocorticoids is sufficient.

Key points to consider:

• Continue current daily dose of glucocorticoids for patients with SLE on chronic steroid therapy undergoing surgery
• Avoid supraphysiologic doses of glucocorticoids to minimize infection risk and hemodynamic instability
• Coordinate care between rheumatologist, anesthesiologist, and surgeon to optimize perioperative management
• Consider individual patient factors, such as baseline steroid dose and severity of SLE, when making decisions about glucocorticoid therapy.

From the Research

Steroid Use for Preoperative Patients with SLE Already on Steroid

• The use of steroids in patients with Systemic Lupus Erythematosus (SLE) is a common practice to manage disease activity and prevent flares 2, 3, 4.
• For patients with SLE who are already on steroid treatment, the decision to continue or adjust the steroid dose before surgery should be made on a case-by-case basis, considering the patient's disease activity and overall health status 5.
• There is evidence to suggest that pulse dose steroid therapy may be effective in managing severe SLE manifestations, including lupus flares, in hospitalized patients 6.
• However, the accuracy of pulse dose documentation extracted from electronic health records (EHRs) is crucial to ensure reliable assessment of steroid dosing in patients with SLE 6.

Considerations for Preoperative Steroid Use in SLE Patients

• The goal of preoperative steroid use in SLE patients is to minimize the risk of disease flare and ensure optimal disease control during the perioperative period 2, 3.
• The choice of steroid dose and duration of treatment should be individualized based on the patient's disease severity, medical history, and surgical procedure 4, 5.
• Close monitoring of the patient's disease activity and adjustment of the steroid dose as needed is essential to prevent disease flare and minimize potential side effects 2, 3.

Evidence-Based Recommendations

• Current treatment guidelines for SLE recommend a treat-to-target approach, aiming to reduce or discontinue glucocorticosteroid (GC) therapy while maintaining disease control 3.
• The use of biologic therapies, such as belimumab and anifrolumab, has shown promise in achieving glucocorticoid-free clinical remission in patients with SLE 5.
• Further research is needed to determine the optimal steroid dosing regimen for preoperative patients with SLE and to develop evidence-based guidelines for steroid use in this population 2, 3, 4, 5, 6.