Perioperative Corticosteroid Management for Patients with Inflammatory Bowel Disease

Abstract

Guidelines on the appropriate use of perioperative steroids in patients with inflammatory bowel disease (IBD) are lacking. As a result, corticosteroid supplementation during and after colorectal surgery procedures has been shown to be highly variable. A clearer understanding of the indications for perioperative corticosteroid administration relative to preoperative corticosteroid dosing and duration of therapy is essential. In this review, we outline the basic tenets of the hypothalamic-pituitary-adrenal (HPA) axis and its normal response to stress, describe how corticosteroid use is thought to affect this system, and provide an overview of the currently available data on perioperative corticosteroid supplementation including the limited evidence pertaining to patients with inflammatory bowel disease. Based on currently existing data, we define "adrenal suppression," and propose a patient-based approach to perioperative corticosteroid management in the inflammatory bowel disease population based on an individual's historical use of corticosteroids, the type of surgery they are undergoing, and HPA axis testing when applicable. Patients without adrenal suppression (<5 mg prednisone per day) do not require extra corticosteroid supplementation in the perioperative period; patients with adrenal suppression (>20 mg prednisone per day) should be treated with additional perioperative corticosteroid coverage above their baseline home regimen; and patients with unclear HPA axis function (>5 and <20 mg prednisone per day) should undergo preoperative HPA axis testing to determine the best management practices. The proposed management algorithm attempts to balance the risks of adrenal insufficiency and immunosuppression.

Perioperative Assessment and Optimization in Major Colorectal Surgery: Medication Management

“…2 In fact, between 25 and 40% of IBD patients will be steroid dependent during their disease course. [2][3][4][5] Corticosteroids modulate the inflammatory response by inhibiting the production of specific proinflammatory markers by way of hypothalamic-pituitary access. As a result, steroids impair wound healing, have a negative effect on glycemic control, and increase postoperative infections, thereby increasing morbidity.…”

“…2 In this patient population, testing for the presence of adrenal insufficiency may be appropriate, and can be determined by the treating physician and medical team. 3 When glucocorticoids are no longer necessary, it is important to provide a taper. There are no standardized guidelines available for tapering, leading to wide variation in clinical practice.…”

“…The dosages of these medications can range from low (less than 5 mg equivalents of prednisone daily) to supraphysiologic (greater than 10 mg equivalents of prednisone daily). 3 For patients on low doses, glucocorticoids can be continued at the same dose in perioperative period. 6 The administration of "stress-dose" steroids was once more prevalent, to decrease the risk of adrenal insufficiency, but has more recently been called into question.…”

The Association of Coloproctology of Great Britain and Ireland consensus guidelines in surgery for inflammatory bowel disease

“…However, the dose of cortisone required to cause adrenal insufficiency is unknown, as is the duration of treatment that can accurately predict its development, although it is commonly believed that several weeks of systemic corticosteroid supplementation are required before adrenal gland function is suppressed. What is known is that subjects on corticosteroids may be able to respond to surgical stress by increasing endogenous corticosteroids and do not necessarily require large doses of steroid . Friedman performed 35 major orthopaedic surgeries among 28 patients receiving chronic steroids (mean daily dose of prednisone 10 mg) without administration of stress‐dosed corticosteroids and noted no clinical evidence of adrenal insufficiency .…”

Perioperative Considerations in Crohn Disease and Ulcerative Colitis

“…26 Given these findings, some have proposed standardized algorithms for the management of perioperative stress dose steroids in an effort to balance patient safety and risk. 27…”