Abstract and Introduction
Myriad questions regarding perioperative management of patients on glucocorticoids (GCs) continue to be debated including which patients are at risk for adrenal insufficiency (AI), what is the correct dose and duration of supplemental GCs, or are they necessary for everyone? These questions remain partly unanswered due to the heterogeneity and low quality of data, studies with small sample sizes, and the limited number of randomized trials. To date, we know that although all routes of GC administration can result in hypothalamic-pituitary-adrenal (HPA) axis suppression, perioperative adrenal crisis is rare. Correlation between biochemical testing for AI and clinical events is lacking. Some of the current perioperative management recommendations based on daily GC dose and duration of therapy may be difficult to follow in clinical practice. The prospective and retrospective studies consistently report that continuing the daily dose of GCs perioperatively is not associated with a higher risk for adrenal crises in patients with GC-induced AI. Considering that oral GC intake may be unreliable in the early postoperative period, providing the daily GC plus a short course of IV hydrocortisone 25 to 100 mg per day based on the degree of surgical stress seems reasonable. In patients who have stopped GC therapy before surgery, careful assessment of the HPA axis is necessary to avoid an adrenal crisis. In conclusion, our literature review indicates that lower doses and shorter duration of supplemental GCs perioperatively are sufficient to maintain homeostasis. We emphasize the need for well-designed randomized studies on this frequently encountered clinical scenario.
Glucocorticoids (GCs) are one of the most commonly prescribed drugs with an estimated use prevalence of approximately 1% of the US population. They are very effective anti-inflammatory medications and considered first-line treatment for many autoimmune conditions. One important consequence of supraphysiological and/or long-term GC treatment is the potential for hypothalamic-pituitary-adrenal (HPA) axis suppression leading to GC-induced adrenal insufficiency (AI), which is associated with increased morbidity and mortality. When associated with a stressor such as a surgical procedure, HPA axis suppression can result in adrenal crisis. This outcome was recognized in early-20th-century studies when adrenalectomized dogs experienced circulatory shock after laparotomy that could be prevented by administering GCs.[3,4] In the 1950s, multiple reports described patients on chronic GC therapy for rheumatoid arthritis who died shortly after orthopedic surgery. Postmortem examinations consistently revealed bilateral adrenal atrophy, leading to the conclusion that the adrenal glands' inability to respond to surgical stress was the cause of death.[5–7] The resultant concern about postoperative adrenal crisis in patients on GCs led to the routine use of high-dose perioperative GC replacement in clinical practice.
Currently, there is little high-quality evidence supporting routine perioperative use of high-dose GCs.[8–11] While underdosing perioperative GCs may place patients at risk for cardiovascular collapse, high doses carry a risk of hyperglycemia, hypertension, opportunistic infections, bone loss in a state of immobility, venous thromboembolism, and poor wound healing.[12–14] This review outlines the key physiologic aspects of the stress response to surgery, the effect of different forms of GCs on the HPA axis, the evidence for perioperative GC administration, and our personalized approach to perioperative management in adults with GC-induced AI.
J Endo Soc. 2023;7(2) © 2023 Endocrine Society