What is the optimal perioperative management of corticosteroids (steroids) in a patient with chronic corticosteroid use?

From the Guidelines

Patients on chronic steroid therapy require stress-dose steroids during the perioperative period to prevent adrenal insufficiency, with the specific regimen depending on the type and magnitude of surgical stress, as well as the patient's underlying condition and steroid dose 1.

Key Considerations

• For minor procedures, patients should receive their usual daily dose of steroids.
• For moderate surgical stress, administer hydrocortisone 50-75 mg/day or equivalent for 1-2 days.
• For major surgeries, give hydrocortisone 100-150 mg/day or equivalent for 2-3 days, with a typical regimen of hydrocortisone 100 mg IV immediately before surgery, followed by 50 mg IV every 8 hours for 24 hours, then taper to the patient's baseline dose over the next 1-2 days as they recover.

Patient Risk Assessment

• Patients who have been on prednisone ≥5 mg daily (or equivalent) for more than 3 weeks within the past year should be considered at risk for hypothalamic-pituitary-adrenal axis suppression 1.

Monitoring and Management

• Monitor for signs of adrenal insufficiency including hypotension, tachycardia, weakness, nausea, and confusion.
• Resume the patient's regular steroid regimen as soon as possible after surgery, typically when they can tolerate oral medications.

Evidence-Based Recommendations

• The guidelines from the Association of Anaesthetists, the Royal College of Physicians, and the Society for Endocrinology UK provide recommendations for the management of glucocorticoids during the perioperative period for patients with adrenal insufficiency 1.
• These guidelines emphasize the importance of individualized glucocorticoid supplementation during the perioperative period, taking into account the patient's underlying condition, steroid dose, and type of surgery.

From the FDA Drug Label

Increased dosage of rapidly acting corticosteroids is indicated in patients on corticosteroid therapy who are subjected to any unusual stress before, during, and after the stressful situation

The FDA recommends increasing the dosage of rapidly acting corticosteroids in patients on corticosteroid therapy who are subjected to unusual stress, such as perioperative periods. This is to prevent adrenal insufficiency due to the suppression of the hypothalamic-pituitary-adrenal (HPA) axis. The exact dosage and duration of the increased corticosteroid therapy are not specified and should be individualized based on the patient's condition and response to treatment 2.

From the Research

Perioperative Steroid Management

Perioperative steroid management in patients with chronic steroid use is a crucial aspect of anesthesia care. The following points highlight the key considerations:

• Patients on chronic steroid therapy are at risk of adrenal insufficiency during the perioperative period, which can lead to major complications such as adrenal crisis 3.
• The concept of perioperative "stress dose" of corticosteroids is evolving, with ongoing debates about the need and appropriate dosage 3, 4.
• Pharmacokinetic studies suggest that lower doses of hydrocortisone can be safely administered to patients with adrenal insufficiency undergoing major surgery 4.
• The current practice of administering excessive glucocorticoid supplementation during stress is being questioned, and more studies are needed to determine the optimal dosage 4, 5.

Key Recommendations

• Patients should take their regular daily dose of steroid preoperatively, regardless of dose or chronicity of prior treatment 6.
• Additional stress dose steroid dosing should be based on patient risk of adrenal suppression and surgical complexity and stress 6.
• The recommended use of lower doses of glucocorticoids during surgical and medical stress should not de-emphasize the importance of additional supplementation during such events 7.
• Clinical judgment is essential in managing patients with adrenal insufficiency during illness or surgery, and recommendations should not replace individualized care 7.

Considerations for Steroid Supplementation

• The invasiveness of surgery and inhibition of the hypothalamus-pituitary-adrenal axis should be evaluated when deciding on steroid supplementation 5.
• The dosage of glucocorticoids should be equivalent to the normal physiological response to surgical stress, which is approximately 100 mg of cortisol for major surgery 5.
• More studies are needed to determine the optimal dosage and administration of stress-dose glucocorticoids during the perioperative period 5, 6.