Should a patient with adrenal insufficiency on hydrocortisone (cortisol replacement) who is started on dexamethasone (glucocorticoid) for a brain tumor and is undergoing surgery continue hydrocortisone and receive stress-dose adjustments?

From the Guidelines

For a patient with adrenal insufficiency on hydrocortisone who is started on dexamethasone for a brain tumor and is going for surgery, the hydrocortisone should be continued alongside dexamethasone, and the hydrocortisone dose should be increased to stress dosing for the perioperative period, as recommended by the guidelines from the Association of Anaesthetists, the Royal College of Physicians, and the Society for Endocrinology UK 1.

Rationale for Continuing Hydrocortisone

The primary reason for maintaining hydrocortisone is that it provides both glucocorticoid and mineralocorticoid effects necessary for stress response and electrolyte balance in adrenal insufficiency, whereas dexamethasone primarily reduces brain edema around the tumor with minimal mineralocorticoid effect. Abruptly stopping hydrocortisone could precipitate an adrenal crisis, especially during the stress of surgery.

Stress Dosing Recommendations

Typically, stress dosing involves administering 100 mg of hydrocortisone intravenously before surgery, followed by a continuous infusion of hydrocortisone at 200 mg/24 h, until the patient can take double their usual oral glucocorticoid dose by mouth. This regimen is preferred due to enhanced safety, as noted in the guidelines 1. The dose should then be tapered back to the maintenance dose, usually within 48 hours, but may be continued for up to a week if surgery is more major or complicated, with clinical judgment guiding this decision.

Importance of Collaboration with Endocrinologist

Once the patient has recovered from surgery, their endocrinologist should reassess the hydrocortisone dosing, considering that high-dose dexamethasone provides significant glucocorticoid activity, which may allow for some reduction in hydrocortisone maintenance dose while continuing both medications.

Key Considerations

• Dexamethasone's Role: Dexamethasone is not adequate as glucocorticoid treatment in patients with primary adrenal insufficiency due to its lack of mineralocorticoid activity 1.
• Hydrocortisone Administration: Hydrocortisone is administered parenterally in the peri-operative period until normal enteral function returns, with intravenous infusion being the preferred method for maintaining plasma cortisol concentrations seen in a normal stress response 1.
• Patient Vulnerability: Patients with comorbidities, such as asthma and diabetes, and those with mineralocorticoid or vasopressin dependency, are more vulnerable to adrenal crisis and require careful management 1.

From the FDA Drug Label

In patients on corticosteroid therapy subjected to any unusual stress, increased dosage of rapidly acting corticosteroids before, during, and after the stressful situation is indicated. Drug-induced secondary adrenocortical insufficiency may result from too rapid withdrawal of corticosteroids and may be minimized by gradual reduction of dosage This type of relative insufficiency may persist for months after discontinuation of therapy; therefore, in any situation of stress occurring during that period, hormone therapy should be reinstituted. If the patient is receiving steroids already, dosage may have to be increased.

The patient with adrenal insufficiency on hydrocortisone (cortisol replacement) who is started on dexamethasone (glucocorticoid) for a brain tumor and is undergoing surgery should continue hydrocortisone and may require stress-dose adjustments of hydrocortisone during the stressful situation of surgery 2.

From the Research

Adrenal Insufficiency and Glucocorticoid Replacement

• Patients with adrenal insufficiency on hydrocortisone (cortisol replacement) who are started on dexamethasone (glucocorticoid) for a brain tumor and are undergoing surgery may require adjustments to their glucocorticoid regimen 3, 4.
• The diagnosis of adrenal insufficiency is made with a stimulation test such as the ACTH test, and treatment should follow the principles for treatment of central adrenal insufficiency 3.
• During stress periods, such as surgery, patients with adrenal insufficiency may require increased doses of glucocorticoids to prevent adrenal crisis 4, 5.

Stress-Dose Adjustments

• The indication for adding stress dosages of glucocorticoid during ongoing glucocorticoid treatment remains unclear 3.
• However, it is recommended that patients with adrenal insufficiency receive stress-dose adjustments during periods of increased stress, such as surgery or intensive endurance exercise 4, 5.
• The goal of stress-dose adjustments is to prevent adrenal crisis and improve outcomes in patients with adrenal insufficiency 5, 6.

Management of Glucocorticoid-Induced Adrenal Insufficiency

• Glucocorticoid-induced adrenal insufficiency is a common condition that can occur in patients taking exogenous glucocorticoids 3, 7.
• Factors affecting the risk of glucocorticoid-induced adrenal insufficiency include the duration of glucocorticoid therapy, mode of administration, glucocorticoid dose and potency, and individual susceptibility 7.
• A careful approach to glucocorticoid taper and appropriate patient counseling are needed to assure a successful taper and prevent adrenal crisis 7.