Perioperative Steroids: Use Low Dose for a Short Time

WASHINGTON — When administering perioperative steroids to patients with suspected tertiary adrenal insufficiency, it's best to use the smallest possible dose for the shortest possible period of time.

“We should do our best to match the stress of the surgical procedure with the dose,” said Dr. Darrell W. Harrington, chief of the division of general internal medicine at Harbor-University of California, Los Angeles Medical Center.

The potential for adrenal crises poses a challenge in patients who are subjected to surgical stress but who are not receiving adequate corticosteroid supplementation. Data are inadequate “to allow reliable prediction of which patients are at risk for tertiary adrenal insufficiency,” he said at the annual meeting of the American College of Physicians.

“What we think we know is that there is no significant suppression if patients take a low dose [of steroids] daily.” Alternately, if patients take an every-other-day dose—usually less than 10 mg prednisone equivalent—there is little hypothalamic-pituitary-adrenal (HPA) axis suppression. Abbreviated exposures, ranging from 5 days to 3 weeks, are probably not associated with significant HPA axis suppression.

However, significant suppression does occur with high doses, superpotent topical steroids, and inhaled corticosteroids. Recovery after prolonged exposure may take as little as 5 days, or as long as a year.

“Unfortunately, there are a lot of patients who fall in between,” Dr. Harrington said. The data for these patients are inconsistent. Most patients on chronic steroids or with a history of steroid use do not have an obvious diagnosis of tertiary adrenal insufficiency. “We have to rely on clinical intuition to make this diagnosis.”

A random cortisol measurement works well at identifying patients who are likely to have HPA reserve. In addition, an adrenocorticotropic hormone (ACTH) stimulation test resulting in an incremental increase of cortisol greater than 9 mcg/dL indicates adequate HPA reserve. But biochemical abnormalities revealed by such tests “do not correlate or predict safety from a clinical events point of view,” Dr. Harrington noted.

The potential for impaired wound healing and increased infection rates related to the perioperative use of exogenous steroids makes some clinicians reluctant to adequately supplement. No clear, consistent evidence shows that wound healing is substantially delayed or impaired when patients are given short courses of perioperative steroids. And data from case series suggest that limited exposure to steroids in surgery patients is associated with a very limited increase in infection risk.

Dr. Harrington reported that he had significant financial relationships with Sanofi-Aventis, Eisai Inc., GlaxoSmithKline, and Pfizer Inc.

WASHINGTON — When administering perioperative steroids to patients with suspected tertiary adrenal insufficiency, it's best to use the smallest possible dose for the shortest possible period of time.

“We should do our best to match the stress of the surgical procedure with the dose,” said Dr. Darrell W. Harrington, chief of the division of general internal medicine at Harbor-University of California, Los Angeles Medical Center.

The potential for adrenal crises poses a challenge in patients who are subjected to surgical stress but who are not receiving adequate corticosteroid supplementation. Data are inadequate “to allow reliable prediction of which patients are at risk for tertiary adrenal insufficiency,” he said at the annual meeting of the American College of Physicians.

“What we think we know is that there is no significant suppression if patients take a low dose [of steroids] daily.” Alternately, if patients take an every-other-day dose—usually less than 10 mg prednisone equivalent—there is little hypothalamic-pituitary-adrenal (HPA) axis suppression. Abbreviated exposures, ranging from 5 days to 3 weeks, are probably not associated with significant HPA axis suppression.

However, significant suppression does occur with high doses, superpotent topical steroids, and inhaled corticosteroids. Recovery after prolonged exposure may take as little as 5 days, or as long as a year.

“Unfortunately, there are a lot of patients who fall in between,” Dr. Harrington said. The data for these patients are inconsistent. Most patients on chronic steroids or with a history of steroid use do not have an obvious diagnosis of tertiary adrenal insufficiency. “We have to rely on clinical intuition to make this diagnosis.”

A random cortisol measurement works well at identifying patients who are likely to have HPA reserve. In addition, an adrenocorticotropic hormone (ACTH) stimulation test resulting in an incremental increase of cortisol greater than 9 mcg/dL indicates adequate HPA reserve. But biochemical abnormalities revealed by such tests “do not correlate or predict safety from a clinical events point of view,” Dr. Harrington noted.

The potential for impaired wound healing and increased infection rates related to the perioperative use of exogenous steroids makes some clinicians reluctant to adequately supplement. No clear, consistent evidence shows that wound healing is substantially delayed or impaired when patients are given short courses of perioperative steroids. And data from case series suggest that limited exposure to steroids in surgery patients is associated with a very limited increase in infection risk.

Dr. Harrington reported that he had significant financial relationships with Sanofi-Aventis, Eisai Inc., GlaxoSmithKline, and Pfizer Inc.

WASHINGTON — When administering perioperative steroids to patients with suspected tertiary adrenal insufficiency, it's best to use the smallest possible dose for the shortest possible period of time.

“We should do our best to match the stress of the surgical procedure with the dose,” said Dr. Darrell W. Harrington, chief of the division of general internal medicine at Harbor-University of California, Los Angeles Medical Center.

The potential for adrenal crises poses a challenge in patients who are subjected to surgical stress but who are not receiving adequate corticosteroid supplementation. Data are inadequate “to allow reliable prediction of which patients are at risk for tertiary adrenal insufficiency,” he said at the annual meeting of the American College of Physicians.

“What we think we know is that there is no significant suppression if patients take a low dose [of steroids] daily.” Alternately, if patients take an every-other-day dose—usually less than 10 mg prednisone equivalent—there is little hypothalamic-pituitary-adrenal (HPA) axis suppression. Abbreviated exposures, ranging from 5 days to 3 weeks, are probably not associated with significant HPA axis suppression.

However, significant suppression does occur with high doses, superpotent topical steroids, and inhaled corticosteroids. Recovery after prolonged exposure may take as little as 5 days, or as long as a year.

“Unfortunately, there are a lot of patients who fall in between,” Dr. Harrington said. The data for these patients are inconsistent. Most patients on chronic steroids or with a history of steroid use do not have an obvious diagnosis of tertiary adrenal insufficiency. “We have to rely on clinical intuition to make this diagnosis.”

A random cortisol measurement works well at identifying patients who are likely to have HPA reserve. In addition, an adrenocorticotropic hormone (ACTH) stimulation test resulting in an incremental increase of cortisol greater than 9 mcg/dL indicates adequate HPA reserve. But biochemical abnormalities revealed by such tests “do not correlate or predict safety from a clinical events point of view,” Dr. Harrington noted.

The potential for impaired wound healing and increased infection rates related to the perioperative use of exogenous steroids makes some clinicians reluctant to adequately supplement. No clear, consistent evidence shows that wound healing is substantially delayed or impaired when patients are given short courses of perioperative steroids. And data from case series suggest that limited exposure to steroids in surgery patients is associated with a very limited increase in infection risk.

Dr. Harrington reported that he had significant financial relationships with Sanofi-Aventis, Eisai Inc., GlaxoSmithKline, and Pfizer Inc.