Peri-operative guidelines for patients with or at risk of adrenal insufficiency (Guidelines)

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)

(*) 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)

(*) 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

(*) dose equivalent from NICE Inhaled corticosteroid doses for NICE asthma guideline (2018)

Steroid treatment advice for adults during intercurrent illness (when you are unwell)