What is the post-operative tapering protocol for hydrocortisone (cortisol) in a patient who underwent adrenalectomy due to pheochromocytoma?

From the Guidelines

After adrenalectomy for pheochromocytoma, hydrocortisone should be tapered gradually to allow the remaining adrenal gland to resume normal function, starting with hydrocortisone 100 mg intravenously at induction, followed by a continuous infusion of hydrocortisone at 200 mg/24 h, and then doubling the regular oral replacement dose for 48 h or up to a week following major surgery, as recommended by the guidelines from the Association of Anaesthetists, the Royal College of Physicians, and the Society for Endocrinology UK 1.

Post-Operative Tapering Protocol

The tapering protocol should be as follows:

• Start with hydrocortisone 100 mg intravenously at induction, followed by a continuous infusion of hydrocortisone at 200 mg/24 h, as recommended by the guidelines 1.
• Once the patient can take oral medication, transition to oral hydrocortisone, doubling the regular oral replacement dose for 48 h or up to a week following major surgery, as recommended by the guidelines 1.
• Taper the dose by reducing it by 10 mg every 3-5 days, monitoring for signs of adrenal insufficiency, such as fatigue, nausea, hypotension, and electrolyte abnormalities.
• Morning cortisol levels should be checked periodically during the taper, with a target morning cortisol >10 μg/dL before complete discontinuation.

Patient Education

Patients should be educated about adrenal insufficiency symptoms and the need for stress dosing during illness, typically triple the maintenance dose, as recommended by the guidelines 1.

Key Considerations

• The hypothalamic-pituitary-adrenal axis is often suppressed after removal of a catecholamine-secreting tumor, and the remaining adrenal tissue needs time to recover its ability to produce cortisol adequately.
• The typical tapering schedule takes 4-6 weeks, but may be extended to 2-3 months in patients who had bilateral adrenalectomy or pre-existing adrenal suppression.
• Clinical judgment should be used to guide the tapering schedule, taking into account the patient's individual needs and response to treatment.

From the FDA Drug Label

The initial dosage of hydrocortisone tablets may vary from 20 mg to 240 mg of hydrocortisone per day depending on the specific disease entity being treated. If after long-term therapy the drug is to be stopped, it is recommended that it be withdrawn gradually, rather than abruptly

The FDA drug label does not provide a specific post-operative tapering protocol for hydrocortisone in patients who underwent adrenalectomy due to pheochromocytoma.

• The label recommends individualized dosing and gradual withdrawal after long-term therapy, but does not address the specific scenario of post-operative tapering after adrenalectomy.
• Key considerations include disease entity, patient response, and stressful situations, but the label does not provide explicit guidance on tapering hydrocortisone in this context 2.

From the Research

Post-Operative Tapering Protocol for Hydrocortisone

• The post-operative management of patients who underwent adrenalectomy due to pheochromocytoma may require steroid replacement therapy, but the specific tapering protocol for hydrocortisone is not directly stated in the provided studies 3, 4, 5, 6, 7.
• However, one study mentions that patients with Cushing's syndrome who underwent bilateral adrenalectomy were treated with hydrocortisone 100 mg iv every eight hours, which was then gradually reduced to 10-20 mg/die by mouth for six-twelve months 3.
• Another study notes that a patient who underwent bilateral laparoscopic cortical-sparing adrenalectomies was weaned off postoperative steroids by week five 5.
• A study on long-term outcomes of surgical treatment for hereditary pheochromocytoma found that 21 of 27 patients (78%) who underwent cortical-sparing adrenalectomy were steroid independent at 3-year follow-up 6.
• It is essential to note that the tapering protocol may vary depending on the individual patient's condition and the surgeon's or endocrinologist's preference.

Considerations for Steroid Replacement Therapy

• Patients who undergo bilateral adrenalectomy are at risk of acute adrenal insufficiency and may require lifelong steroid replacement therapy 4, 6, 7.
• Cortical-sparing adrenalectomy can help avoid the need for steroid replacement therapy in some patients, but it may also increase the risk of pheochromocytoma recurrence 4, 5, 6.
• The decision to use steroid replacement therapy and the tapering protocol should be made on a case-by-case basis, taking into account the patient's overall health and the specific characteristics of their condition.