What is the stress dose for corticosteroids (steroids) before surgery?

From the Guidelines

The stress dose of steroids before surgery for patients on chronic steroid therapy is not necessary for most patients, and the current dose of glucocorticoids should be continued, rather than administering perioperative supra-physiologic glucocorticoid doses. However, for patients who are on physiological corticosteroid replacement because of disorders of the hypothalamic pituitary axis, supplementary doses in the perioperative period may be necessary, such as hydrocortisone 100 mg intravenously on induction, followed by immediate initiation of a continuous infusion of hydrocortisone 200 mg/24 h 1.

Key Considerations

• The decision to restart antirheumatic therapy should be based on careful assessment of the patient’s wound status and clinical judgment for absence of surgical and non–surgical site infections 1.
• Patients who are taking more than 5 mg prednisolone may receive a single steroid dose prior to induction, such as dexamethasone 4 mg intravenous or intramuscular 1.
• The exact dosing may vary based on the patient's underlying condition, the type of steroid they normally take, and the invasiveness of the surgical procedure.

Perioperative Management

• Patients should inform their surgical team about their steroid use well before the scheduled procedure to ensure appropriate perioperative management.
• For patients with primary and secondary adrenal insufficiency, recommended doses for intra- and postoperative steroid cover are outlined in guidelines from the Association of Anaesthetists, the Royal College of Physicians, and the Society for Endocrinology UK 1.
• The dosing should be tapered back to the patient's maintenance dose over 1-2 days as they recover.

Important Notes

• Chronic steroid use suppresses the hypothalamic-pituitary-adrenal axis, preventing the body from mounting an appropriate cortisol response to the stress of surgery.
• Without supplementation, patients may experience an adrenal crisis characterized by hypotension, shock, and even death.
• The literature review found information on hemodynamic instability in a systematic literature review on patients with rheumatic diseases whose mean prednisone (or equivalent) dose was ≤16 mg/day 1.

From the Research

Corticosteroid Stress Doses Before Surgery

• The requirement for perioperative supplemental (stress) doses of corticosteroids in patients receiving long-term corticosteroid therapy and undergoing a surgical procedure was evaluated in a systematic review of the literature 2.
• The study found that patients receiving therapeutic doses of corticosteroids who undergo a surgical procedure do not routinely require stress doses of corticosteroids so long as they continue to receive their usual daily dose of corticosteroid.
• Adrenal function testing is not required in these patients because the test is overly sensitive and does not predict which patient will develop an adrenal crisis.
• However, patients receiving physiologic replacement doses of corticosteroids owing to primary disease of the hypothalamic-pituitary-adrenal axis require supplemental doses of corticosteroids in the perioperative period.

Equivalent Doses of Corticosteroids

• A study evaluated the dose equivalency of major corticosteroids, including hydrocortisone, methylprednisolone, dexamethasone, and prednisolone, using pharmacokinetics and cell trafficking and cortisol dynamics 3.
• The study found that currently used dosing tables reflect reasonable dose equivalency relationships for four corticosteroids.
• Another study compared the differences in clinical outcome and laboratory results in hospitalized patients with severe SARS-CoV2 Pneumonia treated with dexamethasone at 6 mg doses versus patients treated with high-dose methylprednisolone 4.
• The study found that high-dose methylprednisolone for three days followed by oral prednisone for 14 days statistically significantly decreased the recovery time, the need for transfer to intensive care, and the severity markers C-reactive protein (CRP), D-dimer, and LDH compared to 6 mg dexamethasone for 7 to 10 days.

Pharmacokinetics and Pharmacodynamics of Glucocorticoids

• A study reviewed the pharmacokinetics and pharmacodynamics of systemically administered glucocorticoids, including hydrocortisone, prednisolone, methylprednisolone, and dexamethasone 5.
• The study found that glucocorticoids have pleiotropic effects that are used to treat diverse diseases and that clinical efficacy depends on glucocorticoid pharmacokinetics and pharmacodynamics.
• Simulations with a pharmacokinetic/pharmacodynamic model suggested that the clinical efficacy of low-dose glucocorticoid regimens might be increased with twice-daily glucocorticoid administration.