Adrenal response to stress can vary broadly from patient to patient. For hospitalists, the challenge is predicting patients’ cortisol needs.
The variability exists whether one is dealing with a healthy patient or a patient with adrenal insufficiency (AI).1 Glucocorticoid use is even more complicated in patients with chronic autoimmune or inflammatory disorders who have been treated with high doses of glucocorticoids, or with those who are hypothalamic-pituitary-adrenal (HPA) axis suppressed.
Additionally, glucocorticoid administration is the most common cause of AI. Guidelines for adrenal supplementation therapy published in JAMA in 2002 note the difficulty in determining exact patient needs. JAMA’s review of guidelines for adrenal supplementation therapy is based on expert opinion, extrapolation from research literature, and clinical experience rather than clinical trials and should be consulted for more specific patient recommendations.2
Around the same time, similar guidelines on the management of rheumatoid arthritis (RA) patients on chronic glucocorticoids were published in the Bulletin on the Rheumatic Diseases.3 The guidelines suggest lower doses and shorter therapy than many textbooks advocate to counter problems associated with excessive steroid dosing. Problems such as immunosuppression, hyperglycemia, hypertension, acute psychosis, and accelerated protein catabolism lead to poor wound healing.
Additionally, the guidelines recommend that all patients receiving chronic glucocorticoids with an illness or while undergoing any procedure continue their normal daily glucocorticoid therapy. The authors caution that in patients with rheumatic disease, discontinuation of even low glucocorticoid doses may lead to a significant disease flare. Patients who receive 5 mg or less of prednisone daily do not require additional supplementation—regardless of whether they are undergoing a procedure or have an intercurrent illness. Patients undergoing superficial surgical procedures while less than an hour under local anesthesia (e.g., routine dental work, skin biopsy, minor orthopedic surgery) require their normal daily glucocorticoid dose without additional supplementation.
Patients with primary AI should receive individualized supplemental homeostatic glucocorticoid replacement therapy—usually with 20 to 30 mg of hydrocortisone two to three times daily in divided doses. Adjust based on patient factors and use of concomitant medications. Also consider that mineralocorticoid replacement may be necessary in these patients.
When considering patients for potential use of corticosteroids in the hospital, identify those who may be HPA-axis suppressed versus those who are not. The time to achieve HPA-axis suppression varies among patients. Patients can be considered not suppressed if:
- They have received any glucocorticoid doses for less than weeks; and
- They have received alternate-day glucocorticoid therapy. 4-6
- On the contrary, patients should be assumed to have HPA-axis suppression if they:
- Have received less than 20 mg of prednisone or its equivalent daily for more than three weeks (e.g., 16 mg/day methylprednisolone, 2 mg/ day dexamethasone, 80 mg/ day hydrocortisone); and/or
- Have clinical Cushing’s syndrome (e.g., centripetal obesity, glucose intolerance, proximal myopathy, hypertension, psychological chan-ges, and easy bruisability).
Intermediate patient categories may require HPA axis function testing with cosyntropin to determine if AI is present. TH
Michele Kaufman is a clinical/managed care consultant and medical writer based in New York City.
- Lamberts SWJ, Bruining HA, de Jong FK. Corticosteroid therapy in severe illness. N Engl J Med. 1997 Oct 30;337(18):1285-1292.
- Coursin DB, Wood KE. Corticosteroid supplementation for adrenal insufficiency. JAMA. 2002 Jan 9;287(2):236-240.
- Kelley JT, Conn DL. Perioperative management of the rheumatic disease patient. Bull Rheum Dis. 2002;51(6).
- Nieman LK, Kovacs WJ. Pharmacologic use of glucocorticoids. UpToDate. Waltham, Mass. 2007. Available at: www.pharmacologic use of glucocorticoids
- Nieman LK. Clinical manifestations of Cushing’s syndrome. UpToDate. Waltham, Mass. 2007.
- Welsh GA, Manzullo EF, Nieman LK. The surgical patient taking glucocorticoids. UpToDate. Waltham, Mass. 2007. Available at: www.patients.uptodate.com/topic.asp?file=adrenal