Adrenal Insufficiency and Corticosteroid Management
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- Surgery is a potent activator of the hypothalamic–pituitary axis, and patients with adrenal insufficiency may lack the ability to respond appropriately to surgical stress.
- Patients receiving corticosteroids as anti-inflammatory therapy may rarely develop postoperative adrenal insufficiency. Case reports of presumed adrenal insufficiency from the 1950s led to the widespread use of perioperative “stress-dose” steroids in this population.1,2
- The dose and duration of exogenous corticosteroids required to produce clinically significant tertiary adrenal insufficiency is highly variable, but general principles can be outlined.3
- Daily therapy with 5 mg or less of prednisone (or its equivalent), alternate-day corticosteroid therapy, and any dose given for <3 weeks should not result in clinically significant adrenal suppression.
- Patients receiving >20 mg/d prednisone (or equivalent) for >3 weeks and patients who are clinically “cushingoid” in appearance can be expected to have significant suppression of adrenal responsiveness.
- The function of the hypothalamic–pituitary axis cannot be readily predicted in patients receiving doses of prednisone 5–20 mg for >3 weeks