TAM (Treatments and Medicines) NHS HighlandPROCEDURE TYPE | PRE/OPERATIVE NEEDS | POST-OPERATIVE NEEDS |
Any procedure/surgery under anaesthesia | Hydrocortisone 100mg IV just before anaesthesia: then immediately commence continuous infusion at rate of 200mg hydrocortisone/24 hours (8.33mg/hr) See 'post operative needs' and note 'switching back to oral glucocorticoids' | Continue continuous infusion of hydrocortisone 200mg/24 hours (or 50mg IV/IM 6 hourly) while nil by mouth or with post op vomiting. If well then double usual oral dose (unless already on a supraphysiological dose) for minimum of 48 hours if recovery rapid, but for up to 7 days following major surgery, before tapering to usual dose if recovering well |
Labour and normal vaginal delivery | Hydrocortisone 100mg IV/IM at onset of active labour: then immediately commence continuous infusion of 200mg hydrocortisone over 24 hours (or 50mg IV/IM 6 hourly) | Double usual oral dose (unless already on a supraphysiological dose) for minimum of 48 hours after delivery then, if well, return to usual dose |
Minor procedure | Take an extra oral dose eg 10mg hydrocortisone 1 hour before procedure see note 'switching back to oral glucocorticoids' if already on a supraphysiological dose. | Take an extra oral dose 1 hour after procedure (unless on prednisolone or dexamethasone) then return to normal dosing |
Invasive bowel procedures requiring laxatives | Consider admission to hospital overnight for IV fluids and hydrocortisone 100mg IV/IM at start of preparation (especially in those receiving hydrocortisone AND fludrocortisone or desmopressin) Hydrocortisone 100mg IV/IM at start of procedure | Double usual oral dose (unless already on a supraphysiological dose) for 24 hours then, if well, return to usual dose |
Other invasive procedures | Hydrocortisone 100mg IV/IM just before commencing | Double usual oral dose (unless already on a supraphysiological dose) for 24 hours then, if well, return to usual dose |
Major dental surgery | Hydrocortisone 100mg IV/IM just before anaesthesia and consider continuous infusion of 200mg hydrocortisone/24 hours as above if prolonged surgery likely | Double usual oral dose (unless already on a supraphysiological dose) for 24 hours then, if well, return to usual dose |
Dental surgery | Take a double oral dose (max 20mg hydrocortisone, 5mg prednisolone, 0.5mg dexamethasone) 1 hour before surgery in addition to morning dose. see note 'switching back to oral glucocorticoids' if already on a supraphysiological dose. | Double usual oral dose (unless already on a supraphysiological dose) for 24 hours then, if well, return to usual dose |
Other dental procedures | Consider an extra oral dose eg, 5mg hydrocortisone 1 hour before procedure if patient thinks treatment “stressful” | Take an extra dose eg 5mg hydrocortisone where hypoadrenal symptoms occur afterwards, otherwise return to usual dose (Hypoadrenal symptoms include: lethargy, headache, dizziness, nausea and vomiting). |
Peri-operative guidelines for patients with or at risk of adrenal insufficiency (Guidelines)
What's new / Latest updates
New guidance
Individuals with adrenal insufficiency are at risk of a life threatening “adrenal crisis”.
Such patients include individuals with:
- Addison’s disease
- Hypopituitarism
- Those on long term (glucocortico) steroids at risk of iatrogenic adrenal suppression ie. those on prednisolone 5mg equivalent or greater per day for more than 4 weeks, and may include patients on high dose inhaled or topical steroids (see section below “identifying patients at risk of adrenal suppression”).
Such individuals require additional steroids to cope with the stress of a procedure. Steroids may need to be given parenterally depending on the severity of the procedure. Likewise, the patient’s usual dose of steroids may need to be increased for a few days, or longer if there are any surgical complications or infection.
For less invasive procedures the risks of short term administration of one or two additional doses of steroid are unlikely to be of any significant consequence and if in any doubt it is safer to give additional steroids as per the following guidance based on that produced by a group of expert physicians for the UK Addison’s disease self help group https://www.addisonsdisease.org.uk/surgery and the Royal College of Anaesthetists guideline published in 2020 https://onlinelibrary.wiley.com/doi/full/10.1111/anae.14963.
For individuals with Addison's disease or hypopituitarism undergoing surgery it is considered best practice to collaborate with their consultant endocrinologist.
Dose equivalence (See section below)
- Although duration of action and mineralocorticoid activity vary, 5mg prednisolone is roughly equivalent to 15 to 20mg hydrocortisone, 4mg methylprednisolone, 0.5mg dexamethasone.
Postoperative fluid and electrolyte balance
- Daily monitoring of U+Es recommended until individuals are stable on oral hydrocortisone or equivalent. Hyponatraemia may be secondary to inadequate glucocorticoid replacement.
- Intravenous crystalloid fluids are recommended if a patient is nil by mouth.
Continuous vs bolus hydrocortisone replacement
- If adequate intravenous access is available a 200mg/24hour intravenous infusion of hydrocortisone is preferable to 6 hourly IV/IM boluses of 50 to 100mg . This provides more stable hydrocortisone levels, although risks interruption of delivery if there are any intravenous access problems.
- To prepare the infusion: dilute 200mg of hydrocortisone (sodium succinate or sodium phosphate) in 200mls of 0.9% saline or 5% dextrose.
- The 200mg/24hours continuous intravenous infusion should be used for patients on CYP3A4 inducers eg rifampicin, anticonvulsants.
- A single bolus of 6 to 8mg of dexamethasone should suffice for 24 hours in individuals undergoing surgery under anaesthesia on prednisolone or dexamethasone preoperatively but its lack of mineralocorticoid activity which makes it unsuitable for those on hydrocortisone AND fludrocortisone preoperatively ie those with primary adrenal insufficiency including Addison's disease.
Switching back to oral glucocorticoids
- Parenteral hydrocortisone should be continued until the individual is eating and drinking. Ideally give the first oral dose 4 to 6 hours after the last bolus dose or at the time of stopping the continuous infusion, doubling the dose as above.
- If there are any concerns that the patient’s usual hydrocortisone dose may be insufficient, or if the dose is not established, eg post adrenalectomy, then 20mg at breakfast, lunch and tea will usually suffice prior to tapering to a more physiological dose.
- If patients are already on supraphysiological doses of glucocorticoid preoperatively eg 10mg or more prednisolone, or 1.5mg or more dexamethasone per day then doubling of oral dose postoperatively (or for minor procedures) is probably not required, assuming recovery is rapid and uncomplicated.
Possible adrenal crisis
- If at any stage the patient becomes hypotensive and shocked 100mg IV hydrocortisone should be administered in addition to fluid resuscitation.
Under-replacement of glucocorticoids in postoperative period
- Listen to the patient who may be well informed regarding their underlying endocrine condition and increase glucocorticoid dose back to double dose for further 24 to 48 hours if an individual complains of hypoadrenal symptoms such as headache, nausea and non-specific malaise/lethargy as above.
- If significant nausea, vomiting or diarrhoea then parenteral dosing should be considered.
Types of parenteral hydrocortisone
- Hydrocortisone acetate should not be prescribed due to its slower onset of action- use hydrocortisone sodium phosphate or hydrocortisone sodium succinate.
Mineralocorticoid replacement
- Fludrocortisone dose does not usually need to be given whilst on parenteral hydrocortisone as this should provide sufficient mineralocorticoid activity.
“At risk” individuals without known adrenal insufficiency
- Treat like an individual on long term prednisolone 5mg and consider prescribing a short 2 to 3 day course of prednisolone 10mg/day depending on the expected speed of recovery.
Other endocrinopathies
- Patients with panhypopituitarism and diabetes insipidus (on desmopressin) should be discussed with their consultant endocrinologist and anaesthetist and are likely to require high dependency care for careful monitoring of fluid balance following major surgery.
For more detailed discussion of glucocorticoid replacement for dental procedures see SPS
The Society for Endocrinology (SFE) recently published guidance (https://www.endocrinology.org/media/4091/spssfe_supporting_sec_-final_10032021-1.pdf) on identifying individuals at risk of iatrogenic adrenal suppression who should be provided with a steroid emergency card.
There is significant variability in the susceptibility to adrenal suppression eg 10% of individuals on high dose inhaled glucocorticoids will have evidence of adrenal suppression.
Individuals on inhaled steroids, or having received an intra-articular glucocorticoid injection, co-prescribed CYP3A4 inhibitors such as antifungals and protease inhibitors will be at high risk.
Likewise patients on high dose inhaled glucocorticoids plus other glucocorticoids such as nasal or high dose topical steroids will be at higher risk.
If a patient is Cushingoid due to exogenous steroids it is almost certain they will have adrenal suppression.
In addition, individuals receiving 3 or more intra-articular steroid injections within 12 months should be considered at risk, including for 12 months thereafter.
A high degree of clinical suspicion is required to prevent the potentially life threatening consequences of an adrenal crisis. The following tables include information on glucocorticoid dose equivalence and doses risking adrenal suppression. The table are taken from the SFE guidance.
Table 1: Long-term oral glucocorticoids (ie 4 weeks or longer)
Medicine | Dose risking adrenal suppression (*) |
Beclometasone | 625 microgram per day or more |
Betamethasone | 750 microgram per day or more |
Budesonide | 1.5mg per day or more (***) |
Deflazacort | 6mg per day or more |
Dexamethasone | 500 microgram per day or more (**) |
Hydrocortisone | 15mg per day or more (**) |
Methylprednisolone | 4mg per day or more |
Prednisone | 5mg per day or more |
Prednisolone | 5mg per day or more |
(*) dose equivalent from BNF except (**) where dose reflects that described in the guideline by Simpson et al (2020) and (***) based on best estimate
Table 2: Short-term oral glucocorticoids
(one week course or longer AND has been on long-term course within the last year OR has regular need for repeated courses - 3 or more courses within past 12 months)
Medicine | Dose risking adrenal suppression(*) |
Beclometasone | 5mg |
Betamethasone | 6mg per day or more |
Budesonide | 12mg (***) |
Deflazacort | 48mg per day or more |
Dexamethasone | 4mg per day or more (**) |
Hydrocortisone | 120mg per day or more (**) |
Methylprednisolone | 32mg per day or more |
Prednisone | 40mg per day or more |
Prednisolone | 40mg per day or more |
(*) dose equivalent from BNF except (**) where dose reflects that given associated Guidance (Simpson et al 2020) and (***) based on best estimate
Table 3: Inhaled glucocorticoid doses
Medicine | Dose risking adrenal suppression(*) |
Beclometasone (as non-proprietary, Clenil, Easihaler, or Soprobec) | More than 1000 microgram per day |
Beclometasone (as Qvar, Kelhale or Fostair) | More than 500 microgram per day (check if using combination inhaler and MART regimen) |
Budesonide | More than 1000 microgram per day (check if using combination inhaler and MART regimen) |
Ciclesonide | More than 480 microgram per day |
Fluticasone propionate | More than 500 microgram per day |
Fluticasone furoate (as Trelegy and Relvar) | More than 200 microgram per day |
Mometasone | More than 800 microgram per day |
(*) dose equivalent from NICE Inhaled corticosteroid doses for NICE asthma guideline (2018)
| Abbreviation | Meaning |
| IM | Intramuscular |
| IV | Intravenous |
| U&Es | Urea and electrolytes |