Do patients taking prednisone (corticosteroid) need to stop the medication before undergoing surgery?

Perioperative Prednisone Management

For elective surgery, prednisone should be stopped or dose-minimized preoperatively whenever possible to reduce postoperative complications, but patients who have been on steroids for more than 4 weeks must continue receiving equivalent intravenous hydrocortisone during the perioperative period to prevent adrenal crisis—stress-dose steroids are not necessary. 1

Key Decision Algorithm

Step 1: Determine if Stopping is Feasible

• For elective surgery: Attempt to stop corticosteroids or reduce to the lowest dose that prevents disease deterioration before proceeding with surgery 1
• Target dose: Optimize to <20 mg/day prednisone when possible, as doses ≥20 mg significantly increase infection risk and complications 1
• High-risk threshold: Doses ≥40 mg prednisolone carry the greatest risk for postoperative infectious complications, anastomotic leaks, and venous thromboembolism 1

Step 2: Perioperative Continuation Protocol (If Patient Cannot Stop)

If the patient has been on oral corticosteroids for >4 weeks prior to surgery:

• Continue with equivalent intravenous hydrocortisone while nil by mouth 1
• Conversion ratios: Prednisolone 5 mg = Hydrocortisone 20 mg = Methylprednisolone 4 mg 1, 2
• Give the patient's usual daily dose only—do NOT use "stress-dose" or supra-physiologic dosing 1

Step 3: Intraoperative Management

• Anesthesiologists typically administer a single preoperative dose (e.g., dexamethasone 4 mg IV/IM) for patients taking >5 mg prednisolone 1
• This single dose is sufficient; increasing steroid dosage to cover perioperative stress has no proven value 1, 2

Evidence-Based Rationale

Why Stopping/Minimizing is Critical

Patients undergoing surgery while on corticosteroids face substantially increased risks:

• Superficial surgical site infections increase from 2.9% to 5% (odds ratio 1.72) 3
• Deep surgical site infections increase from 0.8% to 1.8% (odds ratio 2.35) 3
• Anastomotic leaks and dehiscence increase 2-3 fold (odds ratios 2.47 and 3.34) 3
• Mortality increases nearly 4-fold, from 1.6% to 6.0% (odds ratio 3.92) 3
• Venous thromboembolism risk is elevated, requiring appropriate prophylaxis 1, 2

Why Stress-Dosing is Unnecessary

The 2017 American College of Rheumatology/American Association of Hip and Knee Surgeons guideline found no significant hemodynamic difference between patients given their current daily glucocorticoid dose versus those receiving "stress-dose steroids" in randomized controlled trials 1. The British Society of Gastroenterology confirms this in both 2019 and 2025 guidelines, stating there is "no value increasing steroid dosage to cover stress in the perioperative period" 1.

Why Continuation is Necessary for Chronic Users

Patients on steroids for >4 weeks have suppressed hypothalamic-pituitary-adrenal (HPA) axis function and cannot mount an adequate cortisol response to surgical stress 4. Abrupt withdrawal risks adrenal crisis, which is why equivalent IV dosing must continue perioperatively 1.

Postoperative Management

Resumption and Tapering

• Resume oral prednisolone as soon as the patient can tolerate oral intake 1, 2
• Implement standardized taper protocols to avoid inappropriate prolongation of steroids after surgery 1, 2
• Taper depends on preoperative dose and duration of steroid use 1
• For patients with complete resection of active disease, avoid prolonging steroids unnecessarily 1

Monitoring for Complications

• Watch for wound healing problems, infections, and signs of adrenal insufficiency 2, 5
• Patients on chronic steroids should wait at least 3-4 weeks post-surgery before additional procedures due to wound healing complications 2

Important Caveats

Exception: Physiologic Replacement Therapy

Patients on physiologic corticosteroid replacement for hypothalamic-pituitary axis disorders (e.g., hydrocortisone 20 mg morning, 10 mg midday) DO require supplementary doses in the perioperative period—this is distinct from pharmacologic steroid therapy 1

Emergency Surgery

This guidance applies to elective surgery only. For emergency surgery (e.g., acute severe ulcerative colitis), different protocols apply 1

Dose-Specific Risks

• The CDC defines immunosuppression threshold at ≥20 mg/day prednisone for ≥2 weeks 1
• Observational studies show increased arthroplasty infection risk with long-term steroid use >15 mg/day 1
• In proctocolectomy specifically, ≥20 mg prednisolone is associated with increased complications 1

Common Pitfall to Avoid

Do not confuse the need to continue baseline steroids with the outdated practice of stress-dose steroids. The former prevents adrenal crisis; the latter has been disproven and increases infection risk without benefit 1.