Hospital physicians frequently encounter patients with decreased adrenal reserve (iatrogenic adrenal insufficiency due to long term corticosteroid therapy or, rarely, adrenal or pituitary disease) who undergo invasive procedures or become acutely ill. The physician must be familiar with the indications for steroid replacement as well as the appropriate dosing schedule. A recent article in The Hospitalist (p. 12) discussed this issue and cited two important primary sources.
A JAMA Clinicians Corner piece published in the January 9, 2002 issue made these procedure specific recommendations:
Minor procedure (endoscopy, inguinal hernia repair): 25 mg hydrocortisone or its equivalent on day of procedure only.
Moderate procedure (abdominal surgery): 50-75mg hydrocortisone on day of procedure and taper quickly over 2-3 days to patient’s maintenance dose.
High risk procedure (cardiovascular surgery, extensive abdominal): 100-150 mg hydrocortisone initially, then taper over 1-2 days to patient’s maintenance dose.
Similar recommendations apply to mild, moderate or severe illness, respectively. For critical illness, 50-100 mg hydrocortisone every 6-8 hours for the duration of critical illness is recommended, along with mineralocorticoid replacement, with slower taper after critical period has resolved.
The above regimens may need to be modified according to the patient’s clinical response.
Superficial procedures under local anesthesia lasting one hour or less require continuation of the patients maintenance regimen but no additional supplementation.
Similar recommendations appeared in a review in Bulletin on the Rheumatic diseases, freely available in full text.