Do patients on chronic budesonide (corticosteroid) require stress dosing?

Stress Dosing for Patients on Chronic Budesonide

Patients on chronic budesonide do NOT require routine stress dosing for surgery or acute illness, as budesonide undergoes 90% first-pass hepatic metabolism with minimal systemic absorption and does not typically suppress the HPA axis at standard doses.

Key Pharmacologic Distinction

• Budesonide is fundamentally different from systemic corticosteroids because it has high topical activity but undergoes extensive first-pass hepatic clearance, resulting in minimal systemic bioavailability 1, 2, 3.
• The 90% first-pass metabolism means budesonide produces negligible systemic corticosteroid effects at therapeutic doses, unlike prednisone or other systemic steroids 1.
• At usual dosages, budesonide has little to no effect on adrenal function 3.

Clinical Approach to Stress Dosing Decision

Patients Who Do NOT Need Stress Dosing:

• Patients on inhaled budesonide for asthma or COPD at any dose 3, 4
• Patients on oral budesonide (controlled-release formulations) for Crohn's disease, microscopic colitis, or autoimmune hepatitis without cirrhosis 1, 5
• Patients taking budesonide as monotherapy without recent systemic steroid exposure 2

Patients Who MAY Need Stress Dosing:

• Cirrhotic patients on oral budesonide - these patients lose the protective first-pass metabolism and experience higher systemic exposure, potentially causing HPA suppression 1.
• Patients with portosystemic shunting who are on oral budesonide 1.
• Patients on budesonide who have recently transitioned from systemic steroids (within the past year) - these patients may still have residual HPA suppression from prior systemic therapy 1, 2.

Practical Management Algorithm

For Surgery or Acute Stress:

1. Assess budesonide formulation and liver function:

   • Inhaled budesonide → No stress dosing needed
   • Oral budesonide + normal liver function → No stress dosing needed
   • Oral budesonide + cirrhosis or shunting → Consider stress dosing 1

2. Review steroid history:

   • No systemic steroids in past year → Continue usual budesonide dose
   • Systemic steroids within past year → Follow systemic steroid stress dosing protocols 1

3. Monitor for adrenal crisis:

   • If unexplained hypotension occurs perioperatively that is fluid-unresponsive, administer hydrocortisone 100 mg IV as empiric treatment for possible adrenal insufficiency 1.

Important Caveats

• The mechanism of budesonide obviates the need for dose tapering after induction therapy, unlike systemic steroids 5.
• Budesonide should not be used in cirrhotic patients for autoimmune hepatitis due to loss of first-pass metabolism and risk of systemic side effects 1.
• When transitioning patients from systemic glucocorticoids to budesonide, monitor for adrenal insufficiency symptoms as the systemic steroid effect wears off 2.
• Stress dosing protocols for chronic systemic steroids (≥20 mg/day prednisone equivalent for ≥3 weeks) do NOT apply to budesonide unless the patient has cirrhosis or recent systemic steroid exposure 1.

Emergency Management

• If adrenal crisis is suspected perioperatively (hypotension unresponsive to fluids), give hydrocortisone 100 mg IV immediately, followed by 50 mg IV every 6-8 hours 1.
• Do not delay treatment to confirm diagnosis in unstable patients 1.