Should a 56-year-old man with a history of polymyalgia rheumatica, currently on prednisone (corticosteroid) 10 mg orally (PO) daily for the past 3 months, undergo elective right total knee arthroplasty (TKA) in 24 hours or have a morning serum cortisol level checked first?

Management of Perioperative Glucocorticoids in a Patient with Polymyalgia Rheumatica Undergoing TKA

The patient should proceed with the scheduled total knee arthroplasty while continuing the current daily dose of prednisone (10 mg) without checking morning serum cortisol levels or administering stress-dose steroids. 1

Rationale for Continuing Current Glucocorticoid Dose

• The 2022 American College of Rheumatology/American Association of Hip and Knee Surgeons guidelines conditionally recommend continuing the current daily dose of glucocorticoids rather than administering supraphysiologic "stress doses" for patients with rheumatic conditions undergoing total knee arthroplasty 1
• This recommendation specifically applies to patients receiving ≤16 mg/day prednisone equivalent for their rheumatic condition, which includes our patient on 10 mg daily 1
• Evidence from observational trials and systematic reviews suggests no significant hemodynamic difference between patients given their current daily glucocorticoid dose compared to those receiving stress-dose steroids 1

No Need for Morning Cortisol Testing

• For patients on chronic glucocorticoid therapy for rheumatic conditions, there is no recommendation to check morning serum cortisol levels prior to elective orthopedic surgery 1
• The patient's current dose of 10 mg daily for 3 months is below the threshold of concern (20 mg/day) established by the CDC for immunosuppression risk 1
• Checking cortisol levels would not change management in this scenario as the patient should continue their usual dose regardless 1

Infection Risk Considerations

• The Centers for Disease Control and Prevention considers the cutoff for immunosuppression at 20 mg of prednisone/day for at least 2 weeks 1
• Observational studies demonstrate an increase in arthroplasty infection risk with long-term steroid use >15 mg/day 1
• At 10 mg daily, this patient is below both thresholds, making them an appropriate candidate for elective surgery without additional intervention 1

Polymyalgia Rheumatica Management Context

• Polymyalgia rheumatica typically requires glucocorticoid therapy, with most patients needing between 5-20 mg of prednisone daily for symptom control 1, 2
• Abrupt discontinuation or significant dose reduction could lead to disease flare and potentially complicate postoperative recovery 3, 4
• Studies comparing different glucocorticoid regimens in PMR have shown that maintaining consistent dosing helps prevent symptom recurrence 5, 6

Postoperative Considerations

• The patient should resume their usual 10 mg daily dose of prednisone immediately after surgery 1
• Monitor for signs of disease flare (increased shoulder/hip girdle pain, morning stiffness) or adrenal insufficiency (hypotension, fatigue, nausea) in the postoperative period 1, 3
• Long-term bone health should be monitored, as even low-dose glucocorticoids (≤10 mg/day) can contribute to bone loss in patients with polymyalgia rheumatica 7

Common Pitfalls to Avoid

• Administering unnecessary stress-dose steroids may increase infection risk without providing additional benefit 1
• Withholding the patient's usual glucocorticoid dose could precipitate adrenal insufficiency or disease flare 3, 4
• Checking morning cortisol levels in this scenario would add unnecessary testing and potentially delay the procedure without changing management 1

By following these evidence-based recommendations, the surgical team can proceed with the planned TKA while maintaining appropriate management of the patient's underlying polymyalgia rheumatica.