The surgical patient taking glucocorticoids
- Amir H Hamrahian, MD
Amir H Hamrahian, MD
- Chief, Endocrinology
- Professor of Medicine
- Cleveland Clinic Abu Dhabi
- Sanziana Roman, MD
Sanziana Roman, MD
- Professor of Surgery (Endocrine Surgery)
- Duke University School of Medicine
- Stacey Milan, MD
Stacey Milan, MD
- Assistant Professor of Surgery (Endocrine Surgery)
- Texas Tech University Health Sciences Center El Paso
- Section Editors
- Lynnette K Nieman, MD
Lynnette K Nieman, MD
- Section Editor — Adrenal Disease
- Senior Investigator
- Bethesda, MD
- Sally E Carty, MD, FACS
Sally E Carty, MD, FACS
- Section Editor — Endocrine Surgery
- Professor, Chief, Division of Endocrine Surgery
- University of Pittsburgh School of Medicine
Chronic glucocorticoid therapy can suppress the hypothalamic-pituitary-adrenal (HPA) axis and, during times of stress such as surgery, the adrenal glands may not respond appropriately. Protocols for "stress dose" steroids followed reports in the 1950s of possible surgery-associated adrenal insufficiency due to sudden preoperative withdrawal of glucocorticoids. However, numerous studies have questioned both the need for and the doses of supplemental perioperative glucocorticoid.
The management of the surgical patient on chronic glucocorticoid therapy is reviewed here. Perioperative glucocorticoid regimens for patients taking replacement glucocorticoid for primary adrenal insufficiency are addressed separately. (See "Treatment of adrenal insufficiency in adults", section on 'Surgery'.)
The use of stress doses of glucocorticoids, such as 300 mg/day of hydrocortisone for several days [1-3], had become a common perioperative practice for patients on glucocorticoid therapy, based upon early case reports of intraoperative adrenal crisis after abrupt withdrawal of glucocorticoids [4,5], and the observation that glucocorticoids have a permissive effect on vascular tone and blood pressure . However, a number of reports, including two randomized studies and a systematic review , have questioned the need for supplemental perioperative stress dose glucocorticoids [1,8-13]. The current approach is to determine perioperative glucocorticoid coverage based upon the patient’s history of glucocorticoid intake, as well as the type and duration of surgery planned [2,14-16].
In addition to suppression of the hypothalamic-pituitary-adrenal (HPA) axis, chronic glucocorticoid therapy may cause a number of other problems in the perioperative period:
●Impaired wound healing 
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- CORTISOL SECRETION DURING STRESS
- EFFECT OF EXOGENOUS GLUCOCORTICOIDS
- Nonsuppressed HPA axis
- Suppressed HPA axis patients
- Intermediate patients (HPA suppression unknown)
- - Glucocorticoid use in past year
- - Inhaled and topical glucocorticoids
- - Intra-articular and spinal glucocorticoid injections
- EVALUATION OF HPA AXIS SUPPRESSION
- Intermediate patients
- - Morning serum cortisol
- - ACTH stimulation tests
- Urgent or emergency surgery
- SUMMARY AND RECOMMENDATIONS