Regardless of cancer type or stage, surgery is a common component of an oncology patient’s treatment plan. Many clinical factors are considered in order to optimize the outcome both during and after surgery. One such factor is the decision to use high-dose perioperative steroids in patients who have been on steroids at some point during their treatment regimen. As with many of the clinical decisions made in oncology, some controversy exists regarding the best utilization of steroids during the perioperative period.
Steroids are one of the most commonly used medications both in definitive chemotherapy regimens as well as for cancer-related sequelae and side effects. Much of the controversy over whether or not to use high-dose perioperative steroids revolves around several small studies conducted in the 1950s and 1960s. These studies reported a risk of adrenal insufficiency for up to 1 year after steroids were discontinued if patients did not receive high-dose or stress-dose hydrocortisone (IV doses between 50 mg and 100 mg) perioperatively. Although these studies were not randomized controlled trials, they started a movement towards empirically administering high-dose perioperative steroids to patients who had been on supraphysiologic doses of steroids (prednisone dose >5 mg/day) for more than 3 consecutive weeks in the last 12 months.
Since these studies in the 1950s and 1960s, there unfortunately has not been a series of randomized controlled trials addressing the need for high-dose perioperative steroids. A recent meta-analysis conducted by Marik et al1 showed that patients receiving steroids did not necessarily need high-dose perioperative steroids, just their current steroid dose on the morning of surgery if they were currently taking steroids. If the medical or surgical team had questions about the patient’s adrenal status, they could perform a cosyntropin stimulation test in order to investigate if the patient was at risk for adrenal insufficiency from being adrenally suppressed by chronic steroid use. A retrospective study conducted by Zaghiyan et al2 looked at high dose versus low dose steroids in inflammatory bowel disease patients undergoing colorectal surgery. This study showed no difference in hemodynamic instability between the two study groups, and some of the patients receiving the high-dose steroids actually had increased risk of tachycardia leading to hemodynamic instability.
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Unfortunately, there is no clear cut answer as to how to perioperatively treat oncology patients with steroids. In general, if the patient has received more than 5 mg of prednisone for 3 consecutive weeks over the last 12 months, many physicians will err on the conservative side and treat the patient with high-dose steroids, considering that the benefit outweighs the risk. If there is a question as to the patient’s adrenal state, a cosyntropin stimulation test can be performed to assess the patient’s risk for adrenal insufficiency. Surgeries can also be stratified by how “stressful” they are considered to be to the adrenal axis. Minor surgeries such as hernia repairs would only require the patient’s usual morning dose of steroids. Moderate surgeries such as joint replacements would require the usual morning dose of steroids along with hydrocortisone 50 mg IV prior to the surgery and then 25 mg every 8 hours for 24 hours. Major surgeries such as a colectomy and esophagogastrectomy would require the highest dose of steroids in the form of hydrocortisone 100 mg IV before the surgery and then 50 mg IV every 8 hours for 24 hours.
Readers, we want to hear from you!
- Do you typically treat your oncology patients with high dose perioperative steroids regardless of the last dose used or time off of steroids?
- Do you utilize the cosyntropin stimulation test in order to determine if an oncology patient has a high probability of adrenal suppression?
References
1. Marik PE, Varon J. Requirement of perioperative stress doses of corticosteroids: a systematic review of the literature. Arch Surg. 2008;143(12):1222-1226.
2. Zaghiyan KN, Murrell Z, Melmed GY, Fleshner PR. High-dose perioperative corticosteroids in steroid-treated patients undergoing major colorectal surgery: necessary or overkill? Am J Surg. 2012;204(4):481-486.
