STRESS DOSE STEROIDS

Supplemental Steroid Dosing in Tertiary (Iatrogenic) Adrenal Insufficiency*
(*All patients with Addison’s Disease or ACTH deficiency (i.e., pituitary surgery) require stress-dose steroids!)

1. Who needs supplemental steroids?

HPA axis status	Glucocorticoid exposure	Management
NOT suppressed	<3 weeks Every-other-day therapy AM dose of <5mg prednisone or equivalent*	Take usual AM dose of glucocorticoid.
MAY be suppressed	Intermediate dose glucocorticoid use (5-20 mg prednisone or equivalent/day) Inhaled steroid use Class I topical glucocorticoid use Significant glucocorticoid use in the past year	ACTH stimulation test** vs empiric supplemental steroids without testing.
IS suppressed.	>20mg/day of prednisone or equivalent for >3 wks Clinically Cushingoid appearance	Supplemental steroids.

*Steroid equivalents: 5 mg prednisone = 4mg methylprednisolone =0.75 mg dexamethasone = 20mg hydrocortisone

2. Dosing Recommendations (based upon expert opinion, not randomized trials):

Surgical risk	Examples	Recommendation
Minor surgery	inguinal hernia repair colonoscopy	Take usual AM steroid dose
Moderate surgery	open cholecystectomy TKA	Take usual AM steroid dose plus: 50mg hydrocortisone IV prior to surgery followed by 25mg q8h x24h, then resume usual dose
Major surgery	esophagectomy total colectomy Whipple liver resection	Take usual AM steroid dose plus: 100mg hydrocortisone prior to surgery followed by 50mg q8h x24h, then taper dose by 1/2 per day until maintenance dose reached.

3. Watch for complications! Glucocorticoid Therapy can cause:

• HPA axis suppression
• Impaired wound healing
• Skin thinning and easy bruising
• Reduced bone mass, leading to fracture
• Increased susceptibility to infections
• Insomnia, mania, psychosis

• Ulcer/GI hemorrhage
• Insulin resistance
• Fluid retention/worsened BP control
• Subcapsular cataract formation
• Myopathy/proximal muscle weakness

References:

Coursin DB, Wood KE. Corticosteroid Supplementation for Adrenal Insufficiency. JAMA.2002;287(2):236-240.
Dorin RI, Qualls CR, Crapo LM. Diagnosis of Adrenal Insufficiency. Ann Intern Med. 2003;139(3):194-204.
Lamberts SW, Bruining HA, deJong FH. Corticosteroid therapy in severe illness. N Engl J Med. 1997;337:1285-1292.
Salem M, Tainsh RE, Bromberg J, et al. Perioperative glucocorticoid coverage: a reassessment 42 years after emergence of a problem. Ann Surg. 1994; 219:416-425.
Welsh GA, Manzullo EF, Nieman LK. The Surgical Patient Taking Glucocorticoids. UpToDate version 14.2; www.uptodate.com., printed 7/10/2006.

Updated May 2011

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STRESS DOSE STEROIDS