Should prednisone (corticosteroid) be held or continued in a patient undergoing knee surgery who is currently taking it?

Should Prednisone Be Held for Knee Surgery?

Prednisone should NOT be held for knee surgery—continue the patient's current daily dose throughout the perioperative period without stress-dose supplementation. 1

Key Management Principles

Continue Current Dose (Do Not Hold)

• Patients on chronic glucocorticoids for rheumatic conditions should continue their usual daily dose perioperatively rather than holding the medication or administering supraphysiologic "stress doses." 1

• This recommendation applies specifically to patients taking ≤16 mg/day prednisone equivalent for rheumatic conditions undergoing total knee arthroplasty. 1, 2

• Low-quality RCT evidence demonstrates no significant hemodynamic difference between patients receiving their current daily dose versus stress-dose steroids, making continuation of the usual dose the safer approach. 1

Why Not Hold the Medication?

• Abruptly stopping chronic glucocorticoids risks disease flare and potential adrenal insufficiency, which could complicate the perioperative course. 1

• A randomized, double-blind study demonstrated that patients with secondary adrenal insufficiency who received only their usual daily prednisone dose (without supplementation) did not experience hypotension or tachycardia during major surgical procedures including joint replacements. 3

Why Not Give Stress Doses?

• Stress-dose glucocorticoids increase infection risk without providing hemodynamic benefit in patients on chronic steroids for rheumatic conditions. 1, 2

• The American College of Rheumatology/American Association of Hip and Knee Surgeons explicitly recommend against stress dosing for this population. 1

Dose-Specific Infection Risk Considerations

Optimize Preoperatively When Possible

• The CDC considers 20 mg/day prednisone for ≥2 weeks as the immunosuppression threshold. 1, 4

• Observational studies demonstrate increased arthroplasty infection risk with long-term glucocorticoid use >15 mg/day (odds ratio 1.68 for postoperative infectious complications). 1, 4

• Ideally, patients should be tapered to <20 mg/day prednisone before elective knee surgery when medically feasible. 1

If Patient Is on High-Dose Prednisone

• For patients on >20 mg/day prednisone, attempt gradual taper (e.g., reduce by 5 mg every 3-5 days) prior to elective surgery if the underlying condition permits. 4

• If tapering is not possible due to disease activity, the surgery may need to be delayed or the increased infection risk accepted after informed discussion with the patient. 1

Important Exceptions (When Stress Dosing IS Required)

These Patients DO Need Stress Dosing:

• Primary adrenal insufficiency (Addison's disease): Requires hydrocortisone 100 mg IV before anesthesia, then 100 mg IV every 6-8 hours for 24-48 hours for major surgery. 2

• Secondary adrenal insufficiency from primary hypothalamic disease: Requires perioperative stress dosing similar to primary adrenal insufficiency. 2

• Juvenile idiopathic arthritis patients who received glucocorticoids during childhood developmental stages: May require different management than adult rheumatic disease patients. 1

Practical Algorithm

For Patients on Chronic Prednisone for Rheumatic Conditions:

1. Verify the indication: Is this for a rheumatic condition (RA, SpA, AS, PsA, SLE) or for primary/secondary adrenal insufficiency? 1

2. Check the dose: Is the patient on ≤16 mg/day prednisone? 1

   • If yes → Continue usual daily dose perioperatively
   • If >20 mg/day → Consider preoperative taper if disease permits 4

3. Continue through surgery: Give the usual morning dose on the day of surgery. 1

4. Resume immediately postoperatively: Return to usual daily dose as soon as patient can take oral medications. 5

5. No cortisol testing needed: Morning serum cortisol levels are not indicated for patients on chronic glucocorticoids for rheumatic conditions undergoing elective orthopedic surgery. 5

Common Pitfalls to Avoid

• Do not hold prednisone thinking it will reduce infection risk—this increases the risk of disease flare and adrenal crisis without reducing surgical complications. 1, 3

• Do not administer stress-dose steroids to patients on chronic glucocorticoids for rheumatic conditions—this increases infection risk without hemodynamic benefit. 1, 2

• Do not confuse patients with rheumatic disease on chronic steroids with patients who have primary adrenal insufficiency—these are entirely different populations with different perioperative needs. 2, 5

• Avoid using postoperative prednisone for pain control—while some centers use prednisone postoperatively for analgesia, this practice is associated with higher rates of manipulation under anesthesia, lysis of adhesions, acute kidney injury, and pneumonia without reducing infection rates. 6