Does a patient taking Prednisone (5 mg daily) require stress dose steroids?

From the Guidelines

Yes, a patient taking Prednisone (5 mg daily) requires stress dose steroids, as this dose can cause suppression of the hypothalamo–pituitary–adrenal axis, leading to adrenal insufficiency 1.

Key Points

• The patient's daily dose of 5 mg prednisone can result in hypothalamo–pituitary–adrenal axis suppression, making them at risk of adrenal crisis during stress or illness 1.
• The guidelines recommend individualized glucocorticoid supplementation during the peri-operative period, considering factors such as dose, duration, and degree of physiological stress 1.
• For patients taking 5 mg or more of prednisolone daily, a significant number may not achieve the target cortisol concentration, highlighting the need for stress dose steroids 1.
• The recommended stress dose regimen is hydrocortisone 100 mg by intravenous injection at induction of anesthesia, followed by a continuous infusion of hydrocortisone at 200 mg/24 h-1, until the patient can take double their usual oral glucocorticoid dose by mouth 1.
• It is essential to collaborate with the patient's endocrinologist when planning scheduled surgery and to consider the patient's history of glucocorticoid self-management and previous episodes of adrenal crisis 1.
• In cases where the patient is taking chronic medium/high-dose glucocorticoid therapy, adequate GC replacement is recommended in acute situations, and GC therapy should not be stopped without tapering 1.

The FDA Drug Labels for prednisone (PO) do not address this question.

From the Research

Patient Requirements for Stress Dose Steroids

• A patient taking Prednisone (5 mg daily) may not require stress dose steroids, as studies have shown that patients receiving low-dose prednisone can have a normal hypothalamic-pituitary-adrenal (HPA) axis response 2.
• The requirement for perioperative stress doses of corticosteroids in patients receiving long-term corticosteroid therapy is still a topic of debate, but some studies suggest that patients receiving therapeutic doses of corticosteroids who undergo a surgical procedure do not routinely require stress doses of corticosteroids so long as they continue to receive their usual daily dose of corticosteroid 3.
• Patients with secondary adrenal insufficiency do not experience hypotension or tachycardia caused by inadequate glucocorticoid levels when given only their daily dose of steroids for surgical procedures 4.
• Adrenocortical insufficiency in patients who have orthopaedic operations without receiving supplemental stress steroids appears to be much less common than previously thought, and supplemental exogenous stress glucocorticoids may not be needed to meet the demands of operative stress in these patients 5.

Key Findings

• Patients receiving less than 5 mg of prednisone daily had a normal HPA axis response, whereas those receiving 5 mg or more had widely varied responses 2.
• The average pulse rates and blood pressures were similar in both groups during the perioperative period, and patients with secondary adrenal insufficiency do not experience hypotension or tachycardia caused by inadequate glucocorticoid levels when given only their daily dose of steroids for surgical procedures 4.
• There is no evidence to suggest that patients taking Prednisone (5 mg daily) require stress dose steroids, and the decision to administer stress dose steroids should be based on individual patient needs and medical history 3, 6.