Who needs to be on stress dose steroids and how do you taper them?

This post is about perioperative stress dose steroids, for adult patients, only. 

Who is at risk for perioperative adrenal insufficiency? The goal of stress dose steroids is to prevent hypotension and adrenal crisis/shock. The Society of Hospital Medicine (in one of their great learning modules), states: 

  • Low risk: <5 mg prednisone daily or ❤ weeks of prednisone over the past year
  • Moderate risk: >5 mg prednisone for >3 weeks in the past year
  • High risk: >20 mg prednisone daily for >3 weeks in the past year
  • Obviously, someone with primary adrenal insufficiency is the highest risk. 

What kind of steroid should be used? IV hydrocortisone is the most physiologic (+mineralocorticoid effect) and should be used until the patient can be transitioned back to prednisone/oral steroids. This letter makes an argument for dexamethasone that is interesting–I myself have never seen dexamethasone used for this indication, though. 

Does the kind of surgery affect whether someone should get stress dose steroids? Yes. 

  • Low stress: local anesthesia, ophthalmologic procedures, some small joint or hernia surgeries <1 hour
  • Moderate stress: general anesthesia, open procedures (hysterectomy, hemicolectomy)
  • High stress: lengthy, complex surgeries (CABG, pancreatectomy)
  • Patients at moderate-high risk undergoing moderate-high stress surgeries should be given stress dose steroids in the perioperative period. (Take this with a grain of salt–the objective evidence is very limited and there are good arguments for being even more conservative and only giving steroids to patients at high risk.)
    • Should you test for HPA axis suppression prior to surgery? If the patient is at moderate risk and undergoing moderate or high stress surgery, and you have the time to wait on results, then sure, you can. What test should you use? You can probably get away with an AM cortisol, although the cort stim test is more accurate

How the heck do I taper stress dose steroids? Stress dose steroid tapers, like ALL steroid tapers, are made up. We as a medical community prescribe tapers based on what “sounds reasonable.” What is usually reasonable is something along the lines of: 

  • Moderate stress surgery: 50 mg IV hydrocortisone x1 –> 25 mg Q8H x24-48 hours –> 10 mg prednisone x3-4 days –> usual dose
  • High stress surgery: 100 mg IV hydrocortisone x1 –> 50 mg Q8H x24-48 hours  –> 20 mg prednisone x3-4 days –> 10 mg prednisone x3-4 days –> usual dose 

Some people would advocate going straight from IV hydrocortisone back to the home dose, which is fine if the patient looks clinically well. Patients at higher risk of complications from steroids (hyperglycemia, fluid retention, agitation) should be tapered more quickly and patients at higher risk of adrenal insufficiency should be tapered more slowly.

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