#medtwitter You receive a pre-op request for consult asking about stress dose steroids:
A patient is on 50mg of prednisone for an inflammatory condition (started several weeks ago) & is undergoing an unrelated surgery. What steroid dose would you give on the day of surgery?
A patient is on 50mg of prednisone for an inflammatory condition (started several weeks ago) & is undergoing an unrelated surgery. What steroid dose would you give on the day of surgery?
2/The first question is how much cortisol the body needs. Under normal circumstances, the body produces 10-12mg of cortisol a day (about 3 mg of prednisone). This occurs in a circadian rhythm:
Image source: slideplayer.com/slide/7644164/
Image source: slideplayer.com/slide/7644164/
3/ Under stress, cortisol production increases
Mild stress- ⬆️ 2x
Moderate-severe stress- ⬆️ 3-4x
Life-threatening stress- ⬆️ as high as 10x
This is why individuals with adrenal insufficiency are told to double steroids when sick because adrenal gland ⬆️ cortisol under stress.
Mild stress- ⬆️ 2x
Moderate-severe stress- ⬆️ 3-4x
Life-threatening stress- ⬆️ as high as 10x
This is why individuals with adrenal insufficiency are told to double steroids when sick because adrenal gland ⬆️ cortisol under stress.
4/Supraphysiologic steroid doses(>5mg pred) can cause suppression of the HPA axis ⬇️ CRH/ACTH response leading to ⬇️ cortisol production. Steroids should be tapered if receiving dose pred >20 for 3 weeks or with prolonged use of supraphys doses.
Image source: Wikipedia commons
Image source: Wikipedia commons
5/In fact, prolonged steroid use is the leading cause of secondary adrenal insufficiency. Sometimes even with a slow taper, AI persists because ACTH remains suppressed or adrenal atrophy can occur with prolonged suppression of ACTH.
6/ So at this point you may be opening up the chart to give those stress dose steroids. But, not sooooo fast.
7/ Let's think through steroid equivalency doses. I usually use MD calc, but here is a chart from litfl.com. Let's say you are giving 50mg of IV hydrocortisone before surgery. What is the prednisone dose equivalent? 12.5 mg.
8/ Hydrocortisone& prednisone do have different durations of actions (hydrocort 8-12 hrs, pred 12-36 hours ncbi.nlm.nih.gov/pmc/articles/P…) which you should keep in mind when dosing. If you gave someone 50mg of IV hydrocortisone q8 you would be giving less steroid than 50mg of pred.
9/ So maybe we should 2x the dose of steroid? If the patient undergoes surgery and the body needs cortisol levels of ⬆️4x from baseline levels ie daily total cortisol levels of 40-50 mg. That would only be 10-12.5mg of prednisone, the current dose is more than sufficient.
• • •
Missing some Tweet in this thread? You can try to
force a refresh
