Which patients require stress dose steroids (corticosteroids) perioperatively?

From the Guidelines

Patients who are on chronic steroid therapy (typically prednisone >5 mg daily or equivalent for >2-3 weeks within the past year) or have primary or secondary adrenal insufficiency require stress dose steroids perioperatively to prevent adrenal crisis. The recommended regimen is hydrocortisone 100 mg intravenously at induction of anesthesia, followed by a continuous infusion of hydrocortisone 200 mg/24 h for major surgery, as suggested by the guidelines from the Association of Anaesthetists, the Royal College of Physicians, and the Society for Endocrinology UK 1. For patients with primary or secondary adrenal insufficiency, the guidelines recommend doubling the regular oral replacement dose of hydrocortisone for 48 hours or up to a week following major surgery, before resuming the maintenance dose 1.

Some key points to consider when managing patients with adrenal insufficiency or those on chronic steroid therapy perioperatively include:

• Identifying patients at risk of adrenal crisis, such as those with primary or secondary adrenal insufficiency, or those taking adrenal suppressive doses of steroids (prednisolone equivalent ≥ 5 mg for 4 weeks or longer) 1
• Administering stress dose steroids perioperatively, with the specific regimen depending on the type of surgery and the patient's underlying condition 1
• Collaborating with the patient's endocrinologist when planning scheduled surgery and when caring for postoperative cases, especially for patients with multiple risk factors (age, comorbidities) 1
• Ensuring that patients are educated on "Sick Day Rules" and have a plan in place for managing their condition during periods of physiological stress, such as illness or injury 1

It is essential to prioritize the prevention of adrenal crisis in these patients, as it can be life-threatening if not managed properly. The guidelines provide a framework for managing patients with adrenal insufficiency or those on chronic steroid therapy perioperatively, but individualized care is crucial to ensure the best outcomes. By following these recommendations and considering the specific needs of each patient, clinicians can help minimize the risk of adrenal crisis and ensure a safe and successful perioperative period.

From the FDA Drug Label

This type of relative insufficiency may persist for up to 12 months after discontinuation of therapy; therefore, in any situation of stress occurring during that period, hormone therapy should be reinstituted. This type of relative insufficiency may persist for months after discontinuation of therapy; therefore, in any situation of stress occurring during that period, hormone therapy should be reinstituted.

Patients who have been on corticosteroid therapy for a prolonged period and are undergoing a stressful situation, such as surgery, may need stress dose steroids perioperatively. This includes patients who have:

• Been on corticosteroids for an extended period and are at risk of adrenal insufficiency
• Recently discontinued corticosteroid therapy and are still at risk of adrenal insufficiency
• Underlying conditions that may affect adrenal function, such as hypothyroidism or hyperthyroidism

It is essential to assess each patient's individual situation and consider the risk of adrenal insufficiency when determining the need for stress dose steroids perioperatively 2, 2, 3.

From the Research

Patients Requiring Stress Dose Steroids Perioperatively

• Patients with adrenal insufficiency are at risk of adrenal crisis, usually precipitated by major stress, such as severe infection or surgery, and require early dose adjustments to cover the increased glucocorticoid demand in stress 4
• Patients with primary adrenal insufficiency, such as those with autoimmune adrenalitis, and secondary adrenal insufficiency, such as those with pituitary tumours, may require stress dose steroids perioperatively 4
• Renal allograft recipients receiving baseline prednisone immunosuppression (5-10 mg/day) may not require stress dose steroids, as their endogenous adrenal function plus exogenous baseline immunosuppressive doses of glucocorticoids may be sufficient to meet the demands of physiologic stress 5
• Patients with septic shock and relative adrenal insufficiency may benefit from corticosteroid therapy, with hydrocortisone being the preferred choice, and fludrocortisone added on a case-by-case basis in refractory shock 6
• Patients with adrenal insufficiency using prednisolone or hydrocortisone for glucocorticoid replacement may have different mortality risks, with prednisolone potentially associated with higher mortality in primary adrenal insufficiency 7

Determining the Need for Stress Dose Steroids

• The need for stress dose steroids perioperatively should be determined on a case-by-case basis, taking into account the individual patient's underlying condition, such as adrenal insufficiency, and their current glucocorticoid replacement regimen 4, 5, 6, 7
• The daily glucocorticoid replacement dose in adrenal insufficiency should be individualized, with a recommended dose of 15 to 25 mg of hydrocortisone (or 3 to 5 mg prednisolone) in divided doses, although lower doses may be sufficient for some patients 8