Can a patient be on corticosteroids prior to cholecystectomy (surgical removal of the gallbladder)?

From the Guidelines

Patients on chronic corticosteroid therapy can continue their medication prior to cholecystectomy, but careful management is required to prevent adrenal insufficiency, with stress-dose steroids potentially necessary during the perioperative period, as recommended by the most recent guidelines 1.

Key Considerations

• Patients on long-term corticosteroid therapy (typically doses equivalent to prednisone 5-7.5 mg daily for more than 3 weeks) may require stress-dose steroids during the perioperative period, which can involve administering hydrocortisone 100 mg intravenously before anesthesia induction, followed by 50 mg every 8 hours for 24-48 hours, then tapering back to the maintenance dose 1.
• The rationale for continuing corticosteroids is that chronic use suppresses the hypothalamic-pituitary-adrenal axis, reducing the body's ability to produce endogenous cortisol in response to the stress of surgery, and abrupt discontinuation could lead to adrenal crisis, characterized by hypotension, electrolyte abnormalities, and even cardiovascular collapse 1.
• Surgeons and anesthesiologists should be informed about the patient's corticosteroid use to ensure appropriate perioperative management, and clinical judgment is required to determine the need for stress-dose steroids based on the patient's perioperative condition and surgical risk 1.

Management Strategies

• Continue regular dose of corticosteroids on the day of surgery and throughout the perioperative period for patients on chronic corticosteroid therapy 1.
• Administer stress-dose steroids during the perioperative period for patients on long-term corticosteroid therapy, with hydrocortisone being the drug of choice for stress and rescue dose steroid coverage 1.
• Monitor patients closely for signs of adrenal insufficiency, such as hypotension, and be prepared to administer a rescue dose of steroids if necessary 1.

From the Research

Adrenal Insufficiency and Corticosteroid Use

• Adrenal insufficiency (AI) can occur due to exogenous corticosteroid therapy administered at supraphysiologic dosages for ≥ 1 month 2.
• The risk of AI varies according to the route of administration, disease, treatment dose, and duration of corticosteroid use 3.
• Patients on long-term corticosteroid therapy are at risk of developing AI, which can be life-threatening in the event of an adrenal crisis 4, 5, 6.

Corticosteroid Use Prior to Cholecystectomy

• There is no direct evidence to suggest that patients cannot be on corticosteroids prior to cholecystectomy.
• However, patients on long-term corticosteroid therapy may be at risk of developing AI, which can affect their response to surgical stress 3.
• It is essential to consider the potential risks and benefits of continuing or discontinuing corticosteroid therapy prior to surgery, and to monitor patients closely for signs of AI or adrenal crisis 4, 5, 6.

Management of Adrenal Insufficiency

• Glucocorticoid replacement therapy is the standard treatment for AI, but it can be challenging to manage, especially in patients with complex medical conditions 5, 6.
• Education and training of physicians and patients are crucial to prevent life-threatening emergencies and to ensure optimal management of AI 5.
• The choice of glucocorticoid formulation and dosing regimen should be individualized to minimize the risk of over- or under-treatment 4, 6.