Do corticosteroids (steroids) affect a medical procedure?

From the Guidelines

Steroids can significantly impact medical procedures, and patients taking them should always inform their healthcare provider before undergoing any procedure. According to the most recent and highest quality study, patients on long-term steroid therapy may not require a "stress dose" of steroids before, during, and after the procedure, as long as they continue to take their usual dosage 1. However, the decision to administer a stress dose of steroids should be made on a case-by-case basis, taking into account the patient's individual risk factors and medical history.

Key Considerations

• Patients taking steroids should inform their healthcare provider before undergoing any procedure
• Steroids can impact wound healing, increase infection risk, affect blood glucose levels, and potentially cause adrenal insufficiency during the stress of a procedure
• The specific effects of steroids on medical procedures depend on the type of steroid, dosage, duration of use, and the nature of the procedure
• Patients should never stop taking prescribed steroids suddenly before a procedure without medical guidance, as this could lead to dangerous withdrawal symptoms

Management of Steroid Therapy

• Patients on long-term steroid therapy may not require a stress dose of steroids before, during, and after the procedure, as long as they continue to take their usual dosage 1
• However, some studies suggest that patients with a high probability of hypothalamic-pituitary-adrenal axis suppression may benefit from perioperative steroid replacement therapy 1
• The healthcare team should develop an appropriate plan to manage steroid therapy around the time of the procedure, taking into account the patient's individual risk factors and medical history.

Recommendations

• Patients on long-term steroid therapy should continue to take their usual dosage before, during, and after the procedure, unless otherwise advised by their healthcare provider 1
• Patients with a high probability of hypothalamic-pituitary-adrenal axis suppression may benefit from perioperative steroid replacement therapy 1
• The healthcare team should develop an individualized plan to manage steroid therapy around the time of the procedure, taking into account the patient's medical history and risk factors.

From the FDA Drug Label

Cardio-Renal As sodium retention with resultant edema and potassium loss may occur in patients receiving corticosteroids, these agents should be used with caution in patients with congestive heart failure, hypertension, or renal insufficiency.

Gastrointestinal Steroids should be used with caution in active or latent peptic ulcers, diverticulitis, fresh intestinal anastomoses, and nonspecific ulcerative colitis, since they may increase the risk of a perforation

Musculoskeletal Corticosteroids decrease bone formation and increase bone resorption both through their effect on calcium regulation (i.e., decreasing absorption and increasing excretion) and inhibition of osteoblast function.

The use of steroids may affect a procedure by increasing the risk of:

• Perforation in patients with active or latent peptic ulcers, diverticulitis, fresh intestinal anastomoses, and nonspecific ulcerative colitis
• Bone loss due to decreased bone formation and increased bone resorption
• Edema and potassium loss in patients with congestive heart failure, hypertension, or renal insufficiency Therefore, caution should be exercised when using steroids in patients undergoing a procedure, especially those with pre-existing medical conditions 2.

From the Research

Effect of Steroids on Procedures

• The use of steroids can have significant effects on various procedures, particularly those related to adrenal function and glucocorticoid therapy 3, 4, 5, 6, 7.
• Long-term use of systemic glucocorticoids can lead to adrenal insufficiency, which can be life-threatening if not properly managed 3, 5, 6.
• The withdrawal of long-term glucocorticoids should be done slowly and carefully to minimize the risk of adverse reactions, including adrenal insufficiency 3.
• In some cases, steroid supplementation may be necessary to prevent adrenal crisis, particularly during periods of physiologic stress 4, 6.
• The choice of glucocorticoid replacement regimen can have significant effects on patient outcomes, including mortality and cardiometabolic risk 7.

Adrenal Insufficiency and Steroid Use

• Adrenal insufficiency is a common complication of long-term glucocorticoid use, particularly at high doses 3, 5.
• The diagnosis of adrenal insufficiency can be challenging, and may require careful evaluation and monitoring 3, 5, 6.
• The treatment of adrenal insufficiency typically involves replacement with glucocorticoids, which can be lifelong in some cases 3, 6.
• The use of prednisolone and dual-release hydrocortisone may offer advantages over traditional glucocorticoid replacement regimens, including a smoother glucocorticoid profile and reduced steroid exposure 7.

Procedure-Specific Considerations

• In renal transplant recipients, the use of baseline prednisone immunosuppression may be sufficient to meet the demands of physiologic stress, without the need for additional "stress steroids" 4.
• In patients with severe asthma, the use of biologic therapies may allow for the reduction or elimination of maintenance oral corticosteroids, but careful monitoring for adrenal insufficiency is necessary 5.
• In patients with adrenal crisis, the use of hydrocortisone injection may be preferred over prednisolone suppositories due to its more rapid and reliable absorption 6.