Adrenal Insufficiency and Corticosteroid Management

Adrenal Insufficiency and Corticosteroid Management is a topic covered in the Washington Manual of Medical Therapeutics.

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General Principles

  • 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

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