Is it common to prescribe intravenous (IV) steroids, then switch to oral (PO) steroids with a downward taper over 4 to 6 weeks after unilateral adrenalectomy due to Pheochromocytoma?

From the Guidelines

It is common to prescribe intravenous (IV) steroids initially and then switch to oral (PO) steroids with a downward taper over a period of time after unilateral adrenalectomy for pheochromocytoma, with the goal of preventing adrenal insufficiency and allowing the remaining adrenal gland to recover. The typical regimen begins with IV hydrocortisone, as recommended by the guidelines for the management of glucocorticoids during the peri-operative period for patients with adrenal insufficiency 1. According to these guidelines, hydrocortisone 100 mg by intravenous (i.v.) injection should be given at induction of anaesthesia in adult patients with adrenal insufficiency from any cause, 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. Some key points to consider when managing patients after unilateral adrenalectomy for pheochromocytoma include:

• The importance of collaborating with the patient's endocrinologist when planning scheduled surgery and postoperative care 1
• The need to recognize and diagnose adrenal crisis, a medical emergency that can occur in glucocorticoid-dependent patients 1
• The use of hydrocortisone as the preferred glucocorticoid due to its enhanced safety profile 1
• The need for frequent monitoring of blood pressure, electrolytes, and symptoms of adrenal insufficiency during the tapering period The dose is then gradually tapered over a period of time, with the goal of allowing the remaining adrenal gland to resume normal cortisol production. Most patients will eventually achieve normal adrenal function without long-term steroid replacement, although the exact timing may vary.

From the Research

Unilateral Adrenalectomy and Steroid Replacement

• The provided studies do not directly address the common practice of prescribing intravenous (IV) steroids, then switching to oral (PO) steroids with a downward taper over 4 to 6 weeks after unilateral adrenalectomy due to pheochromocytoma 2, 3, 4, 5, 6.
• However, the studies suggest that unilateral adrenalectomy can be an effective treatment for pheochromocytoma, with some patients able to avoid long-term corticosteroid dependence 3, 4, 5.
• Cortical-sparing adrenalectomy, which aims to preserve adrenal function, has been shown to be a feasible surgical strategy for pheochromocytoma in some patients, with minimal risk of acute adrenal insufficiency 3, 4.

Steroid Replacement Therapy

• The studies do not provide specific information on the use of IV steroids followed by a taper of PO steroids after unilateral adrenalectomy for pheochromocytoma.
• However, it is noted that total bilateral adrenalectomy can lead to acute adrenal insufficiency, which may require steroid replacement therapy 2, 4.
• In some cases, patients who undergo unilateral adrenalectomy may not require steroid replacement therapy, especially if the contralateral adrenal gland is preserved 5.

Surgical Outcomes

• Unilateral adrenalectomy has been shown to be an effective treatment for pheochromocytoma, with improved outcomes in terms of blood pressure control and reduction of antihypertensive medications 6.
• The studies suggest that surgical outcomes can vary depending on the specific surgical approach and patient population, highlighting the need for individualized treatment plans 2, 3, 4, 5, 6.