Should steroids be tapered slowly for several weeks post unilateral adrenalectomy for pheochromocytoma in an 18-year-old male patient who developed hypotension immediately post-operation and was given vasopressors and Solucortef (hydrocortisone) 100mg intravenously (IV) three times a day (TID) until blood pressure readings were low normal?

From the Guidelines

Steroids should be tapered slowly over several weeks post unilateral adrenalectomy for pheochromocytoma in this 18-year-old male patient, as the remaining adrenal gland is likely suppressed and needs time to recover normal function. The patient's postoperative hypotension and need for Solucortef suggests temporary adrenal insufficiency, which is a common complication in such cases 1. A typical regimen would be to transition from IV hydrocortisone to oral hydrocortisone (e.g., 20 mg in the morning and 10 mg in the afternoon) and gradually taper over 4-6 weeks while monitoring for symptoms of adrenal insufficiency.

According to the guidelines for the management of glucocorticoids during the peri-operative period for patients with adrenal insufficiency, hydrocortisone 100 mg by intravenous (i.v.) injection should be given at induction of anaesthesia, 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. This regimen should then be tapered back to the appropriate maintenance dose, in most cases within 48 h, although for up to a week if surgery is more major/complicated - clinical judgement should be used to guide this.

Some key points to consider during the taper include:

• Educating the patient about symptoms of adrenal insufficiency (fatigue, weakness, dizziness, nausea) and stress dosing during illness
• Monitoring blood pressure, electrolytes, and morning cortisol levels during follow-up visits
• Gradually withdrawing exogenous steroids while allowing the remaining adrenal gland to resume normal cortisol production
• Being aware that most patients will regain normal hypothalamic-pituitary-adrenal axis function within 2-3 months, but some may require longer steroid support 1.

It is essential to collaborate with the patient's endocrinologist when planning scheduled surgery and when caring for postoperative patients, as they can provide valuable insights into the patient's history of glucocorticoid self-management and any previous episodes of adrenal crisis 1.

From the FDA Drug Label

Drug-induced secondary adrenocortical insufficiency 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 after long-term therapy the drug is to be stopped, it is recommended that it be withdrawn gradually, rather than abruptly

Steroid tapering is necessary to minimize the risk of secondary adrenocortical insufficiency.

• The patient should be tapered off hydrocortisone gradually, rather than abruptly, to avoid potential complications.
• The duration of tapering should be several weeks, considering the patient's condition and the fact that relative insufficiency may persist for months after discontinuation of therapy 2.
• It is essential to monitor the patient's condition closely during the tapering process to adjust the dosage as needed 3.

From the Research

Steroid Tapering Post-Adrenalectomy

• The patient in question underwent unilateral adrenalectomy for pheochromocytoma and developed hypotension post-operation, requiring vasopressors and Solucortef (hydrocortisone) 100mg intravenously (IV) three times a day (TID) until blood pressure readings were low normal.
• According to 4, glucocorticoid (GC) therapy should be tapered slowly to allow for recovery of the hypothalamic-pituitary-adrenal (HPA) axis, especially after high-dose GC therapy.
• The study 5 suggests that when steroid therapy is to be withdrawn, gradual tapering of the dosage is necessary to avoid exacerbation of the underlying disease or steroid withdrawal syndrome.
• In the context of adrenal insufficiency, 6 recommends chronic glucocorticoid replacement with hydrocortisone 15-25 mg/day in divided doses, and dose monitoring is largely based on clinical judgement.
• The patient's situation is similar to those discussed in 7, where patients with primary adrenocortical insufficiency require lifelong steroid substitution, and the aim is to assess the substitution therapy in regard to metabolic balance, glycaemic effects, and bone mineral density.

Tapering Steroids Post-Operation

• Given the patient's recent surgery and high-dose steroid therapy, it is essential to taper steroids slowly to avoid adrenal crisis, as suggested by 4 and 5.
• The rate of tapering should be based on the patient's clinical response and the duration of high-dose steroid therapy, with slower tapering over a few weeks to allow for recovery of the HPA axis, as recommended by 4.
• Monitoring the patient's blood pressure, electrolyte parameters, and hormonal analyses, as done in 7, can help guide the tapering process and ensure that the patient is not under-replaced or over-replaced with steroids.