Prophylactic Hydrocortisone Before TAHBSO in Euthyroid Patient on Methimazole
No, you should not give prophylactic hydrocortisone to this patient. She does not have adrenal insufficiency and is not at risk for adrenal crisis from her thyroid condition or methimazole therapy.
Why Hydrocortisone is Not Indicated
Your patient has two separate medical issues that do not create a need for stress-dose steroids:
- Toxic nodular goiter controlled on methimazole: She is currently euthyroid on a low maintenance dose (5 mg daily), meaning her thyroid function is normalized 1, 2
- Severe anemia requiring TAHBSO: This is a gynecologic indication unrelated to her thyroid status
Hydrocortisone is only indicated perioperatively for patients with adrenal insufficiency or those at risk of hypothalamic-pituitary-adrenal (HPA) axis suppression 3, 4, 5. Your patient has neither condition.
Who Actually Needs Perioperative Hydrocortisone
The Association of Anaesthetists and Society for Endocrinology UK guidelines specify that stress-dose steroids (hydrocortisone 100 mg IV at induction, followed by 200 mg/24h infusion) are required for 3, 4:
- Patients with diagnosed adrenal insufficiency (primary or secondary)
- Patients on chronic glucocorticoid therapy ≥5 mg prednisolone daily (or ≥20 mg hydrocortisone daily) for ≥1 month 3, 4
Your patient meets neither criterion. Methimazole is an antithyroid drug that blocks thyroid hormone synthesis—it has no glucocorticoid activity and does not suppress the adrenal axis 1.
What You Should Actually Focus On
Preoperative Thyroid Management
Continue her methimazole through surgery since she is euthyroid 1. The key perioperative concerns for toxic nodular goiter are:
- Avoid thyroid storm: Ensure she remains euthyroid perioperatively with continued antithyroid medication 2
- Beta-blockade if needed: Consider perioperative beta-blocker for heart rate control, especially given her severe anemia and cardiovascular stress 6
Anemia Management Priority
With hemoglobin of 72 mg/dL (7.2 g/dL), your immediate priority is optimizing her for surgery:
- Transfusion threshold: She likely needs preoperative blood transfusion given severe symptomatic anemia
- Cardiovascular optimization: Severe anemia increases cardiac stress during surgery
- Timing of surgery: Balance urgency of bleeding control against optimizing hemoglobin
Common Pitfall to Avoid
Do not confuse thyroid disease with adrenal disease. Hyperthyroidism and hypothyroidism affect metabolism and cardiovascular function, but they do not cause adrenal insufficiency 2, 7. The thyroid and adrenal glands are separate endocrine organs with distinct hormone systems.
The only scenario where a patient with thyroid disease would need stress-dose steroids is if they also had concurrent autoimmune adrenal insufficiency (Addison's disease as part of autoimmune polyglandular syndrome), which is not mentioned in your case 5.
Definitive Treatment Planning
After TAHBSO resolves her bleeding, remember that toxic nodular goiter rarely remits with medical therapy alone (95% relapse rate after drug discontinuation) 8. She will eventually need definitive treatment with either:
- Radioiodine ablation (preferred for toxic nodular goiter) 2, 7
- Total thyroidectomy (if radioiodine contraindicated or patient preference) 1, 2
Methimazole is appropriate for achieving and maintaining euthyroidism before definitive therapy, but is not curative 1, 2, 8.