Should I give stress steroids to a patient on 10 mg of prednisone (corticosteroid) for rheumatoid arthritis who has a gram-negative bacterial infection?

Stress Steroids for Patients on Chronic Prednisone with Gram-Negative Bacterial Infection

Stress-dose steroids are not indicated for a patient on 10 mg of prednisone for rheumatoid arthritis who has a gram-negative bacterial infection. The patient should continue their usual daily dose of prednisone without increasing to stress doses 1, 2.

Rationale for Not Administering Stress-Dose Steroids

Current Guidelines on Stress Dosing

• The 2017 American College of Rheumatology/American Association of Hip and Knee Surgeons guideline specifically recommends continuing the current daily dose of glucocorticoids rather than administering perioperative supra-physiologic "stress doses" in patients receiving ≤16 mg/day of prednisone 2.
• This recommendation is based on evidence showing no significant hemodynamic difference between patients given their current daily glucocorticoid dose compared to those receiving stress-dose steroids 2.

Infection Risk Considerations

• The FDA label for prednisone warns that corticosteroids increase the risk of infection with any pathogen, including bacterial infections, and can exacerbate existing infections 1.
• Adding additional steroids in the form of stress dosing may:
  • Further suppress immune function
  • Potentially worsen the gram-negative infection
  • Mask signs of infection progression

Adrenal Suppression Threshold

• According to the FDA label, patients on corticosteroid therapy subjected to unusual stress may need increased dosage before, during, and after the stressful situation 1, 3.
• However, the European League Against Rheumatism (EULAR) guidelines suggest that 10 mg/day of prednisone is considered a low-dose regimen 2.
• The Centers for Disease Control and Prevention considers immunosuppression to occur at doses of 20 mg/day of prednisone for at least 2 weeks 2.

Management Approach for This Patient

Continue Regular Prednisone Dose

• Maintain the current 10 mg daily dose of prednisone for rheumatoid arthritis 2.
• Do not increase to stress-dose steroids as this may worsen infection outcomes 1.

Infection Management

• Treat the gram-negative bacterial infection with appropriate antibiotics based on culture and sensitivity results.
• Monitor closely for signs of clinical deterioration that might indicate adrenal insufficiency:
  • Unexplained hypotension
  • Electrolyte abnormalities
  • Altered mental status

Special Considerations

• If the patient develops hemodynamic instability that is suspected to be due to adrenal insufficiency rather than sepsis, only then consider stress-dose steroids 2.
• For patients with known adrenal insufficiency, physiological replacement steroids (<10 mg prednisone equivalent) should be continued at home dosing throughout treatment for infection 2.

Monitoring During Infection Treatment

• Monitor vital signs, particularly blood pressure, for signs of hemodynamic instability
• Check electrolytes, particularly sodium and potassium
• Assess for clinical improvement of the infection
• Watch for signs of adrenal insufficiency if the patient has been on long-term steroids

Common Pitfalls to Avoid

1. Unnecessary stress dosing: Administering stress-dose steroids to patients on low-dose prednisone (≤10 mg/day) without evidence of adrenal insufficiency may increase infection risk 2, 1.

2. Abrupt discontinuation: Never abruptly stop the patient's baseline prednisone dose during infection treatment, as this could precipitate adrenal crisis 1.

3. Overlooking infection progression: Corticosteroids can mask signs of infection, so careful monitoring is essential 1.

4. Assuming all patients on steroids need stress doses: The need for stress dosing depends on dose, duration of therapy, and individual patient factors 2.