Glucocorticoid supplementation for adrenal insufficiency & patients on long-term steroids.
Decision support based on Woodcock et al, Anaesthesia 2020 (Association of Anaesthetists /
RCP / SfE / RCoA). Always check against the source guideline and your local policy; not a substitute for
clinical judgement. If in doubt, give steroids — short-term cover carries no long-term harm.
Steroid
Daily dose (mg)
Taken for 4 weeks or longer?
Inhaled, topical, intranasal and intra-articular steroids can suppress
the HPA axis with regular use ≥1 month. If in doubt, treat as at-risk and give cover.
The 8 key recommendations of the source guideline
Prescribed glucocorticoids — prednisolone ≥5 mg/day in adults (10–15 mg.m⁻²/day hydrocortisone-equivalent in children), by any route for ≥1 month — can suppress the HPA axis; this is the commonest cause of adrenal insufficiency anaesthetists meet.
All glucocorticoid-dependent patients are at risk of adrenal crisis with surgical stress or illness. If in doubt, give glucocorticoids — there is no long-term harm from short-term administration.
Patients with long-standing adrenal insufficiency are often expert in their own disease — ask about their self-management and previous crises, and collaborate with their endocrinologist.
Give hydrocortisone 100 mg IV at induction, then a continuous infusion of 200 mg/24 h, until the patient can take double their usual oral dose; taper to maintenance (usually within 48 h, up to a week after major surgery). Use IM if IV is impractical.
Major complications and critical illness excite a prolonged stress response — supplementation should reflect this.
Dexamethasone is inadequate glucocorticoid cover in primary adrenal insufficiency (no mineralocorticoid activity).
Children are more prone to hypoglycaemia — monitor glucose frequently; dose by age/weight (Table 3); minimise fasting and prioritise on the list.
In obstetric adrenal insufficiency, a higher maintenance dose may be needed from ~20 weeks; give hydrocortisone 100 mg at the onset of labour, then 200 mg/24 h infusion (or 50 mg IM 6-hourly) until after delivery.
Source of evidence. Woodcock T, Barker P, Daniel S, Fletcher S, Wass JAH, Tomlinson JW, et al.
Guidelines for the management of glucocorticoids during the peri-operative period for patients with adrenal insufficiency:
guidelines from the Association of Anaesthetists, the Royal College of Physicians and the Society for Endocrinology UK.
Anaesthesia 2020;75(5):654–63. doi:10.1111/anae.14963. Correction: Anaesthesia 2020;75(9):1252. doi:10.1111/anae.15210.
Equivalences use standard anti-inflammatory ratios (approximate) for threshold screening only.
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