Stress-Dose Steroids: A Reflex the Evidence Has Quietly Moved Past
Everyone in the room learned to reach for hydrocortisone the moment a chronic steroid user goes to the OR. The newer literature says that reflex may be treating a crisis that, at her steroid dose and this surgery's severity, was never actually coming.
M.T., a 58-year-old woman, has been on prednisone 5 mg daily for polymyalgia rheumatica for just over ten years, well-controlled and otherwise active — she still teaches watercolor classes twice a week — and is now scheduled for an intermediate-risk procedure, a laparoscopic hysterectomy for symptomatic fibroids. The surgical team's reflexive plan is the traditional stress-dose hydrocortisone protocol, the same regimen taught for decades to any chronic steroid user facing surgery, on the theory that HPA-axis suppression from years of exogenous steroid could leave her unable to mount an adequate cortisol response to surgical stress.
That teaching was built largely around higher chronic doses and major surgery, and her actual regimen sits well below the threshold most consistently associated with clinically significant suppression — 5 mg daily is roughly physiologic replacement, not the 20 mg-plus doses the traditional literature's worst-case scenarios were drawn from. Current risk stratification, set out in the Endocrine Society's perioperative review, places prednisone at or under 5 mg daily in the low-risk tier where supplementation is not indicated regardless of duration — but her 5 mg sits exactly on that boundary rather than under it, and the medium-risk tier the same review defines begins at the number she takes. Prete's meta-analysis of the cortisol stress response to surgery supplies the other half of the reason the older teaching is loosening: the response to an intermediate-risk procedure is a good deal smaller than the maximal figures the traditional regimen was scaled against.
She herself raises the question before the team gets to it, having read online that stress-dose steroids can cause their own problems — hyperglycemia, impaired wound healing, occasional psychiatric effects — and asks plainly whether the traditional regimen is actually protecting her from something or just following a rule nobody has re-checked against her specific case. It's a fair question the pre-operative note hadn't fully anticipated, and one the team ultimately treats as reason enough to settle the underlying physiology directly rather than falling back on the reflexive answer either way.
Pre-operative planning, three days before surgery
I'd still give the traditional stress-dose hydrocortisone here — ten years of chronic steroid use is the textbook scenario this protocol exists for, and the cost of an under-treated intraoperative adrenal crisis is more severe than the cost of unnecessary supplementation.
I'd push back on treating this as the textbook scenario. Her dose is 5 mg, roughly physiologic replacement and an order below the greater-than-20 mg tier the traditional regimen was built from. The Endocrine Society's stratification puts 5 mg and under in the low-risk group, and Prete's meta-analysis shows the cortisol response to an intermediate-risk procedure falls well short of the maximal-stress figures that regimen was scaled to. Continuing her home dose with monitoring is a defensible plan, not under-treatment — though I'll concede she sits on the boundary of that tier rather than comfortably inside it.
We don't have to infer her axis status from dose and duration alone — a low-dose ACTH stimulation test would answer this directly, and her surgery isn't urgent enough to preclude getting it done beforehand. If her response is adequate, continuing home dose with monitoring is well-supported; if it's blunted, that's a real, specific finding justifying supplementation rather than a population-level guess in either direction.
The ACTH stimulation test, performed two days before surgery, showed an adequate cortisol response. Her home prednisone dose was continued unchanged through the perioperative period with close intraoperative hemodynamic monitoring; no stress-dose hydrocortisone was given, and her surgery and recovery proceeded without any hemodynamic instability suggesting adrenal insufficiency.
The anesthesiologist noted for the record that this reassured him for this specific patient without changing his general practice for higher chronic doses or major surgery, where he still considers the traditional regimen the safer default absent a similarly reassuring test.