Stress-Dose Steroids

HPA axis status

Glucocorticoid (GC) exposure

Management

NOT suppressed

<3 weeks

Every-other-day therapy

AM dose of <5 mg prednisone or equivalent^a

Take usual AM dose of GC

MAY be suppressed

Intermediate-dose GC use (5–20 mg prednisone or equivalent/day)

Inhaled GC use

>3 GC intra-articular or spinal injections in the past 3 months

Class I topical GC use^b

Significant GC use in the past year

Check 8 AM serum cortisol (24 h off usual GC dose) vs. empiric supplemental GC without testing

If <5mcg/dL, supplemental GC

If >10mcg/dL, take usual AM dose of GC

If 5–10mcg/dL, do ACTH stimulation test [4] vs. empiric supplemental GC

IS suppressed

>20 mg/day of prednisone or

equivalent for >3 weeks

Clinically Cushingoid appearance^c

Supplemental GC

^a5 mg prednisone = 4 mg methylprednisolone = 0.75 mg dexamethasone = 20 mg hydrocortisone

^bClass I topical glucocorticoids include betamethasone dipropionate 0.05 %, clobetasol propionate 0.05 %, diflorasone diacetate 0.05 %, fluocinonide 0.1 %, and halobetasol propionate 0.05 %

^cProminent central obesity, “moon” facies, dorsocervical fat pad, and/or bulging supraclavicular fat pads

Recovery from tertiary adrenal insufficiency may take months [2, 5], so the clinical history should include all GC use within the past year.

All patients with primary adrenal insufficiency (Addison’s disease) or ACTH deficiency (hypothalamic/pituitary dysfunction) have inadequate GC production [2].

Perioperative Management

If you decide that supplemental dose steroids are indicated for a patient, use Table 14.2 to find the recommended dose. These recommendations are based on expert opinion, as only two small prospective trials on this topic exist [1, 6]. Consider:

Table 14.2

Dosing for supplemental glucocorticoid administration [6]

Surgical risk

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