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Steroid Supplementation — FRCA Final MCQ

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ModeratePreoperative AssessmentSteroid SupplementationFRCA Final

A 60-year-old man has taken oral prednisolone 15 mg each morning for 6 months for polymyalgia rheumatica. He is undergoing elective total hip arthroplasty, and his hypothalamo-pituitary-adrenal axis has not been formally assessed. Which perioperative glucocorticoid regimen is most appropriate?

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Correct answer: C — Continue his usual prednisolone, give hydrocortisone 100 mg IV at induction, then 200 mg over 24 hours by IV infusion while nil by mouth

Option C is correct. Prednisolone 15 mg daily for 6 months is sufficient to cause hypothalamo-pituitary-adrenal suppression, and total hip arthroplasty constitutes major surgical stress. UK multisociety guidance recommends continuing the patient's usual glucocorticoid and giving hydrocortisone 100 mg IV at induction, followed by 200 mg over 24 hours by continuous infusion while enteral treatment is unreliable. Hydrocortisone 50 mg every 6 hours is an alternative. Once oral medication is reliable, the preoperative therapeutic prednisolone dose may be resumed after uncomplicated recovery; a higher oral dose may be needed if recovery is complicated. Hydrocortisone 25 mg at induction is inadequate for major surgery, while 100 mg at induction without postoperative cover does not address continuing surgical stress. Oral prednisolone alone is unsuitable when perioperative absorption is uncertain.

Reference: Woodcock T et al. Guidelines for the management of glucocorticoids during the peri-operative period for patients with adrenal insufficiency, adult perioperative dosing tables. Association of Anaesthetists, Royal College of Physicians and Society for Endocrinology UK, 2020. https://pubmed.ncbi.nlm.nih.gov/32017012/