Do patients on long-term 5 mg prednisone (corticosteroid) therapy require stress dose steroids during significant stress?

Stress Dose Steroids for Patients on Long-Term 5 mg Prednisone

Yes, patients on long-term 5 mg prednisone therapy require stress dose steroids during significant physiological stress, as this dose can suppress the hypothalamic-pituitary-adrenal axis in approximately one-third to half of patients. 1

Evidence for HPA Axis Suppression

Daily glucocorticoid doses equivalent to prednisolone ≥ 5 mg for longer than 1 month represent an adrenal suppressive dose in a significant proportion of adults 1, 2. Case series of short synacthen tests performed in patients receiving 5-20 mg prednisolone daily show that approximately one-third to half of these patients fail to achieve target cortisol concentrations, indicating inadequate adrenal reserve 1.

Stress Dose Recommendations

For Surgical Procedures

The approach should be based on the degree of surgical stress:

• Minor procedures (e.g., colonoscopy, dental work):

  • Continue regular 5 mg prednisone dose
  • No additional supplementation typically needed

• Moderate procedures (e.g., joint replacement, laparoscopic surgery):

  • Continue regular 5 mg prednisone dose
  • Add hydrocortisone 50 mg IV at induction
  • Resume regular prednisone dose post-procedure

• Major procedures (e.g., cardiac surgery, major abdominal surgery):

  • Continue regular 5 mg prednisone dose
  • Hydrocortisone 100 mg IV at induction
  • Follow with hydrocortisone 200 mg/24 hours as continuous infusion or divided doses
  • Taper to regular dose over 1-3 days as recovery progresses 1

For Non-Surgical Stress

• Mild illness (e.g., common cold):

  • Continue regular 5 mg prednisone dose
  • No additional supplementation needed

• Moderate illness (e.g., infection requiring antibiotics):

  • Double the regular prednisone dose (10 mg daily)
  • Return to regular dose when recovered

• Severe illness (e.g., requiring hospitalization):

  • Hydrocortisone 100 mg IV immediately
  • Follow with hydrocortisone 200 mg/24 hours until recovery 1

Rationale and Evidence Quality

The recommendation for stress dosing is based on the risk-benefit analysis. While some systematic reviews have questioned the necessity of routine stress dosing 3, the 2020 guidelines from the Association of Anaesthetists, Royal College of Physicians, and Society for Endocrinology UK emphasize that the risks of inadequate glucocorticoid response outweigh the minimal risks of short-term supplementation 1.

The British Society of Gastroenterology guidelines (2019) similarly support providing stress dose steroids for IBD patients on corticosteroids undergoing surgery, noting that patients on prednisone 5 mg should receive supplemental doses in the perioperative period 1.

Important Caveats

1. Individual variability: The degree of HPA axis suppression varies between individuals on the same dose of prednisone.

2. Duration matters: Longer duration of steroid therapy increases risk of adrenal suppression.

3. Medication errors: A significant concern is medication omission during hospitalization, which can precipitate adrenal crisis 1.

4. Patient education: Patients should be educated about stress dosing requirements and carry medical identification indicating their steroid dependency 4.

5. Monitoring: Watch for signs of inadequate steroid coverage (hypotension, nausea, vomiting, fatigue, confusion) or excessive supplementation (hyperglycemia, fluid retention).

6. Recovery period: After major stress, patients should gradually taper back to their maintenance dose over several days rather than abruptly returning to baseline 5.

Conclusion

Despite some controversy in the literature, current guidelines support providing stress dose steroids for patients on long-term 5 mg prednisone during significant physiological stress. The potential consequences of adrenal crisis far outweigh the minimal risks associated with short-term steroid supplementation.