What is the most appropriate postoperative management plan for a patient who has undergone an adrenalectomy (removal of an adrenal gland) for a cortisol-secreting adenoma (benign tumor) causing Cushing's syndrome?

Postoperative Management After Adrenalectomy for Cortisol-Secreting Adenoma

The correct answer is A: IV hydrocortisone with gradual taper, not lifelong steroids. After unilateral adrenalectomy for a cortisol-secreting adenoma causing Cushing's syndrome, patients develop tertiary adrenal insufficiency due to prolonged suppression of the hypothalamic-pituitary-adrenal (HPA) axis, but this is temporary and recovers over time 1.

Immediate Perioperative Management

Stress-dose hydrocortisone must be administered at surgery and immediately postoperatively because removal of the cortisol-secreting adenoma results in acute tertiary adrenal insufficiency 1. The contralateral adrenal gland has been suppressed by chronic hypercortisolism and cannot immediately respond to surgical stress 2.

Initial Dosing Strategy

• Start with stress-dose hydrocortisone (typically 100 mg IV at induction, followed by 50-100 mg IV every 6-8 hours for the first 24-48 hours) 1
• For pediatric patients, use 2 mg/kg at induction followed by continuous IV infusion based on weight (25-150 mg/24 hours) 1

Tapering Protocol

The key principle is gradual reduction to physiologic replacement doses, not lifelong therapy. The HPA axis typically recovers within 6-18 months after surgery 2.

Structured Tapering Approach

• First 48 hours: Double the usual oral hydrocortisone doses, then reduce to normal replacement doses over up to a week 1
• Maintenance phase: Continue physiologic replacement doses (typically 15-25 mg hydrocortisone daily in divided doses) until HPA axis recovery is documented 1
• Monitor with serial morning cortisol levels to guide steroid tapering and assess HPA axis recovery 1

Why Not Lifelong Steroids?

Unilateral adrenalectomy for cortisol-secreting adenoma does NOT require lifelong replacement because only one adrenal gland is removed and the contralateral gland recovers function 2. This contrasts sharply with bilateral adrenalectomy, which does require lifelong glucocorticoid and mineralocorticoid replacement 3.

Evidence of HPA Axis Recovery

• Studies demonstrate that the HPA axis recovers as shown by normalization of short synacthen-stimulated cortisol levels (peak ≥20 µg/dL) after a median follow-up of 9 months (range 6-18 months) 2
• Postoperative ACTH levels rise from suppressed to normal or elevated, indicating recovery of pituitary function 4, 2
• All patients achieve biochemical cure with 8 a.m. basal cortisol ≤5 µg/dL initially, followed by gradual normalization 2

Critical Monitoring During Recovery

Patients require close surveillance during the recovery period to prevent adrenal crisis and guide appropriate tapering 1.

Essential Monitoring Components

• Serial morning cortisol measurements to assess HPA axis recovery and guide when to discontinue replacement 1
• Regular endocrine follow-up to assess signs of adrenal insufficiency requiring dose adjustment 1
• Stress-dose coverage during intercurrent illness, trauma, or subsequent surgery until HPA axis recovery is confirmed 1

Patient Education Requirements

All patients must be educated on "sick day rules" until HPA axis recovery is documented 1:

• Double steroid doses during illness, fever, or significant stress 1
• Carry emergency hydrocortisone and medical alert identification 1
• Seek immediate medical attention for vomiting, severe illness, or inability to take oral medications 1

Common Pitfall to Avoid

The major error is assuming lifelong replacement is needed after unilateral adrenalectomy. This misconception likely stems from confusing unilateral with bilateral adrenalectomy. Only bilateral adrenalectomy requires lifelong glucocorticoid and mineralocorticoid replacement 3. With unilateral adrenalectomy, the remaining adrenal gland will recover once the suppressive effect of excess cortisol is removed 2.

Timeline for Discontinuation

• Most patients can discontinue replacement therapy within 6-18 months 2
• Confirm recovery with morning cortisol >10-15 µg/dL and/or normal response to ACTH stimulation test before discontinuing 1
• Some patients may recover earlier (as early as 2 days postoperatively in rare cases with preoperative medical therapy) 4