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Steroids — Perioperative Management

The perioperative plan should answer three different questions: does this patient need adrenal replacement or stress coverage, is an antiemetic steroid appropriate, and how does chronic exposure affect healing? A single dexamethasone dose and long-term prednisone therapy have different evidence and risks. This workflow uses the 2024 ESE/Endocrine Society guideline for glucocorticoid-induced adrenal insufficiency.[1]

See also: Corticosteroid pharmacology, Immunosuppression, Nausea & Vomiting, and Wound Healing.

Identify Adrenal-Insufficiency Risk​

Record the drug, route, current and previous doses, duration, recent taper, last dose, prior adrenal testing or crisis and interacting medication. Oral exposure expected to pose risk generally exceeds both 3–4 weeks and a physiologic daily equivalent: approximately hydrocortisone 15–25 mg or prednisone or prednisolone 4–6 mg.[1] The 2020 UK Association of Anaesthetists/Royal College of Physicians/Society for Endocrinology guideline uses a similar rule of thumb: prednisolone 5 mg/day or more for a month or more by oral, inhaled, intranasal, intra-articular or topical routes may suppress the axis.[7]

  • Known adrenal insufficiency and exogenous Cushingoid features require an explicit coverage plan.
  • A current prednisone dose below 5 mg does not prove recovery after a higher-dose course or taper.[1]
  • A genuinely short course under 3–4 weeks usually does not require tapering or routine HPA testing, but consider repeated exposure and the clinical context.
  • Recent discontinuation counts. Mortality is higher in the period just after long-term oral glucocorticoids stop, so a patient who stopped weeks ago without recovery testing is still "at risk" for surgical planning.[1]
  • Inhaled, topical, injected and other non-oral steroids can suppress the axis. Higher potency or dose, prolonged use, simultaneous formulations, recent intra-articular injections and strong CYP3A4 inhibitors increase concern. No single inhaled-dose cutoff clears every preparation or patient.[1]

For patients with current or recent exposure in whom glucocorticoid-induced adrenal insufficiency has not been excluded, the guideline recommends stress coverage during relevant stress (recommendation 3.1, good clinical practice statement). Oral coverage suits minor stress without hemodynamic instability or vomiting; parenteral coverage suits moderate or major stress, general or regional anesthesia, prolonged nil by mouth and instability (3.1A, 3.1B). The route and dose depend on severity, absorption and the baseline regimen.[1]

Testing for Recovery​

When long-term treatment is no longer needed and the patient has reached a physiologic dose, a morning cortisol is the guideline's first test for HPA recovery if testing is chosen. Obtain it at 8–9 AM after an appropriate medication hold, usually at least 24 hours; dexamethasone requires separate consideration. Arrange this with the prescribing team rather than withholding necessary treatment around surgery.[1]

Morning cortisol in this recovery-testing contextGuideline interpretation
Above 10 μg/dL (approximately 300 nmol/L)Recovery is likely; stopping replacement can be considered when the underlying indication permits.
5–10 μg/dLContinue physiologic replacement and repeat after weeks to months.
Below 5 μg/dL (approximately 150 nmol/L)Continue replacement and repeat after a few months.

Interpret values as a continuum, using the assay and clinical setting. Estrogen, low binding proteins, critical illness and sleep disruption affect total cortisol. Routine dynamic testing is discouraged during taper; when necessary, the standard 250-microgram ACTH test and assay-specific interpretation are preferred over routinely using the 1-microgram test.[1]

Preserve Required Treatment Without Duplicating Doses​

Avoid an unplanned interruption of necessary glucocorticoid therapy. If oral treatment cannot be taken or absorbed, prescribe an appropriate parenteral regimen. Count the glucocorticoid exposure supplied by that regimen: do not automatically add the full oral dose again to an IV dose that already replaces it and provides stress coverage. Document the return to the usual treatment, particularly in transplant recipients or active inflammatory disease.[1][2]

Stress Coverage​

The following is a summary of ESE/Endocrine Society Table 8 for adults at risk of or with diagnosed glucocorticoid-induced adrenal insufficiency. These suggested schedules are based substantially on clinical practice; head-to-head evidence is limited and some centers use lower-dose regimens. Agree the plan with anesthesia or endocrinology when risk or recovery is uncertain.[1]

Minor Stress or a Procedure Under Local Anesthesia​

If the patient already takes hydrocortisone at least 40 mg/day, prednisone at least 10 mg/day or dexamethasone at least 1 mg/day, an increase is usually unnecessary for minor stress when stable and absorbing medication.[1]

For a local-anesthetic procedure in someone needing coverage at a lower dose, the table gives oral hydrocortisone 40 mg total: 20 mg one hour before, then 10 mg six hours later and another 10 mg after a further six hours. Prednisone 10 mg or dexamethasone 1 mg one hour before are alternative schedules for patients using those drugs at lower doses. Continue increased coverage if still unwell; do not lower a higher baseline dose to these examples. For illness-type minor stress (fever, antibiotics, bed rest), the table gives hydrocortisone 40 mg/day in three doses, or the prednisone or dexamethasone equivalent, for 2–5 days until well. A bowel procedure without general anesthesia needs only hydrocortisone 20 mg total (10 mg one hour before, 5 mg at six hours, 5 mg six hours later) if the patient is not on daily glucocorticoids; a patient already on them continues the usual dose, given intravenously if nil by mouth is prolonged.[1]

Office cystoscopy, stent exchange, intravesical therapy and scrotal surgery under local anesthesia fit this tier. Cystoscopy or stent work performed under general anesthesia does not automatically follow the office or local schedule.

General or Regional Anesthesia​

Table 8 suggests hydrocortisone 100 mg IV at induction, followed immediately by 200 mg over 24 hours, or 50 mg IV every six hours if infusion is unavailable. Typical urologic examples are TURP, pyeloplasty, ureteral reimplantation, robotic prostatectomy and urethroplasty; the guideline does not classify procedures by name, so match the plan to anesthesia type and expected recovery. For prolonged NPO or long recovery (radical cystectomy with diversion, reconstruction involving bowel, complex posterior urethroplasty, septic emergency surgery, cesarean section), continue the 200 mg/24 h infusion (or 50 mg every six hours) while NPO. Once recovery is uncomplicated and oral absorption is reliable, use increased oral coverage for 48 hours (hydrocortisone 40 mg/day, prednisone 10 mg/day or dexamethasone 1 mg/day are examples), then return to the required preoperative regimen. Preserve a higher baseline dose; infection, reoperation or ongoing illness requires reassessment.[1]

A patient already receiving hydrocortisone at least 200 mg/day, prednisone at least 50 mg/day or dexamethasone approximately 6–8 mg/day usually does not need additional glucocorticoid for moderate or major stress, but the route must remain reliable.[1]

Labor and vaginal delivery use the same 100 mg bolus at onset followed by 200 mg/24 h. Cesarean section is treated as the NPO or long-recovery tier. Primary adrenal insufficiency with mineralocorticoid requirements needs an endocrine plan rather than a generic urologic procedure table.[1]

Suspected Adrenal Crisis​

Consider crisis with hypotension, collapse, severe weakness, vomiting or diarrhea, abdominal pain, fever, altered mental status, hyponatremia, hypoglycemia or unexplained deterioration in a patient with known or possible adrenal insufficiency. Do not wait for fluid-resistant shock or laboratory confirmation. Treat competing causes such as hemorrhage and sepsis simultaneously.[1][2]

  1. Give hydrocortisone 100 mg IV or IM immediately.[1]
  2. Start prompt isotonic fluid resuscitation, guided by perfusion, cardiac and renal status, and ongoing losses. NICE specifies 1 L of 0.9% saline over 30 minutes in adults with crisis; reassess closely for overload.[3]
  3. Continue hydrocortisone 200 mg/24 hours by infusion, or 50 mg IV/IM every six hours.[1]
  4. Monitor blood pressure, heart rate, electrolytes and glucose; treat hypoglycemia and the precipitating illness.
  5. Obtain cortisol and ACTH before treatment if immediately feasible, but never delay hydrocortisone or resuscitation. Arrange endocrine guidance for taper and oral transition.[1][2][3]

Hyperkalemia particularly suggests mineralocorticoid-deficient primary adrenal disease or another cause; aldosterone is usually preserved in glucocorticoid-induced insufficiency, for which routine fludrocortisone is not indicated.[1]

After stabilization, provide a clear sick-day plan, an emergency steroid card or medical alert and access to an emergency hydrocortisone injection kit with training when indicated. Do not assume a universally available autoinjector.[2][3]

Dexamethasone for PONV​

Use the PONV workflow and corticosteroid hub for antiemetic selection and doses. Coordinate this with stress coverage; hydrocortisone replacement has not been established as an equivalent antiemetic regimen. A non-steroid antiemetic may avoid unnecessary duplicate glucocorticoid exposure.

PADDI randomized 8,880 adults undergoing nonurgent noncardiac surgery under general anesthesia, with an expected duration of at least 2 hours, an expected incision length >5 cm and an overnight hospital stay, to a single 8-mg IV dexamethasone dose or placebo. Among 8,678 in the primary analysis, 30-day SSI occurred in 8.1% versus 9.1%, meeting noninferiority; 24-hour PONV was lower.[4] Patients undergoing operations associated with a primary infection and patients with HbA1c above 9% were excluded.[4] In a 2023 systematic review of adults with diabetes undergoing elective surgery, four randomized trials found a mean 39.6 mg/dL higher maximum glucose in the first 24 hours after a single 4–10 mg IV dexamethasone dose for PONV prophylaxis versus control.[16] In PADDI, hyperglycemic events occurred in 22/3,787 participants without diabetes given dexamethasone versus 6/3,776 given placebo.[4] A 2024 synthesis identified 16 randomized placebo-controlled trials involving patients with diabetes; five contributed quantitative data from 2,344 patients to at least one outcome. The analysis did not detect a surgical-site infection difference with short-course dexamethasone, but heterogeneity was high and poorly controlled diabetes remained understudied.[15]

Chronic Exposure and Reconstruction​

Glucocorticoids blunt fibroblast proliferation and collagen synthesis, epithelialization, angiogenesis and neutrophil and macrophage function. A review of animal and human studies found that high-dose systemic corticosteroids for under 10 days had no clinically important effect on wound healing, whereas patients on chronic corticosteroids for at least 30 days before surgery had wound complication rates about 2 to 5 times those of non-users, varying with dose, duration, comorbidity and operation. The animal data (about 30% lower wound tensile strength at 15 to 40 mg/kg/day) are not directly transferable to clinical doses.[5]

Reconstructive risk assessment includes chronic systemic glucocorticoid dose, duration and comorbidities when planning buccal or skin graft take, urethral and ureteral anastomoses, flap survival, open pelvic wounds, bowel anastomoses after diversion or bowel-based reconstruction, and prosthetic implantation.[5]

Before elective reconstruction, coordinate any taper to the lowest dose that safely controls the underlying disease; do not taper solely for surgery when this would destabilize disease or threaten an allograft. Optimize nutrition, glucose, vitamin D and calcium and other modifiable risks, and assess fracture risk under the relevant glucocorticoid-osteoporosis pathway. Consent discussions address the possible increase in wound complications with chronic systemic glucocorticoid exposure, accounting for dose, duration, comorbidities and the planned operation.[5]

Operation-specific guidance should remain scoped. ECCO's 2026 UC surgical guideline recommends tapering corticosteroids below 20 mg prednisolone-equivalent before elective proctectomy or restorative surgery, based on low-level evidence.[6]

Evidence and Controversy​

The Table 8 stress-dose regimens rest on physiology and clinical practice, not randomized comparisons. The ESE/Endocrine Society authors state that head-to-head evidence is lacking, that practice varies among centers, and that lower doses are also routinely used in moderate or major stress.[1] The UK guideline likewise calls for a pragmatic approach and says blanket recommendations are not appropriate.[7]

Small comparative studies have not demonstrated a hemodynamic benefit from routine supraphysiologic dosing when the baseline glucocorticoid dose was continued or given as an IV equivalent; they measured short-term hemodynamic outcomes in mixed surgical populations.[10][11][12]

  • Systematic review. Marik and Varon found nine studies (two randomized trials, seven cohorts; 315 patients, 389 procedures). In the trials, hemodynamics did not differ between stress dosing and the usual daily dose alone. No patient in the five cohorts that continued the usual dose developed unexplained hypotension or adrenal crisis. The two episodes of unexplained hypotension occurred in cohorts in which the usual dose had been stopped 36 to 48 hours before surgery, and both responded to hydrocortisone and fluid.[10]
  • Randomized trial, secondary adrenal insufficiency. Glowniak and Loriaux randomized 18 patients taking prednisone at least 7.5 mg daily, with ACTH-confirmed secondary adrenal insufficiency, to perioperative cortisol or saline on top of the usual prednisone dose. Most had major operations. One patient in each group became hypotensive, and both responded to volume; blood pressure and pulse rate were otherwise similar.[11] The trial is small.
  • Randomized noninferiority trial, colorectal surgery. In 92 steroid-treated patients with IBD having major colorectal surgery, IV hydrocortisone matched to the presurgical oral dose (then tapered) was noninferior to hydrocortisone 100 mg three times daily for postural hypotension on postoperative day 1 (96% versus 95% free of it).[12]
  • Narrative reviews and other guidelines. Freudzon reports a low incidence of perioperative adrenal insufficiency in chronic glucocorticoid users and small studies showing no survival or hemodynamic difference when stress doses were withheld; the studies are limited in size and applicability, and every patient should take the usual daily dose.[9] The 2021 WSES/SIS-E/WSIS/AAST/GAIS guideline on the acute abdomen in immunocompromised patients found no evidence that a push dose is needed for surgery in patients currently taking steroids or treated within the past year, and advised those currently taking steroids to continue their usual regimen.[13] It gives hydrocortisone 100 mg IV for unexplained, fluid-unresponsive hypotension around surgery.[13] Its grades are moderate strength on intermediate- or low-quality evidence, and it defines chronic therapy as prednisone 20 mg/day or more for at least 3 weeks.[13] A 2026 rheumatology review reaches the same practical position: continuing the home dose is adequate for most patients, and stress dosing is reserved for biochemically confirmed adrenal dysfunction or supraphysiologic doses with moderate- or high-risk surgery.[14]

Where the Frameworks Disagree​

The ACR/AAHKS 2022 guideline conditionally recommends continuing the current daily glucocorticoid dose rather than giving supraphysiologic doses on the day of surgery, graded low-quality evidence. Its scope is narrow: adults with rheumatoid arthritis, ankylosing spondylitis, psoriatic arthritis or lupus who take glucocorticoids for that disease and are having elective total hip or knee arthroplasty. It does not apply to primary adrenal insufficiency or primary hypothalamic disease, or to patients with juvenile idiopathic arthritis who received glucocorticoids in childhood. The recommendation is unchanged from the 2017 guideline, and the panel notes that no randomized trials have appeared since then.[8]

The ESE/Endocrine Society 2024 guideline recommends stress coverage for patients with current or recent use in whom adrenal insufficiency has not been excluded. It treats a baseline of prednisone 10 mg/day or more as enough for minor stress and 50 mg/day or more as enough for moderate or major stress.[1]

The approaches differ for some patients on chronic prednisone below 50 mg/day having moderate or major surgery: ESE describes scheduled hydrocortisone stress coverage when adrenal insufficiency has not been excluded.[1] ACR/AAHKS conditionally recommends the usual daily dose instead of supraphysiologic dosing for patients receiving glucocorticoids for RA, AS, PsA or SLE who undergo elective hip or knee arthroplasty; the small mixed-surgery trial above separately found no hemodynamic benefit from supplementation.[8][11] Neither position rests on a large randomized trial.

Practical Default for Low-Dose Chronic Prednisone​

For a patient on chronic prednisone below 10 mg/day having moderate or major surgery under general anesthesia, the following is a lower-intensity practice approach distinct from the ESE/Endocrine Society Table 8 stress-coverage schedule:[1]

  1. Give the usual dose on the morning of surgery and never miss it.
  2. If a lower-dose alternative is selected, specify the intraoperative dose, postoperative coverage, oral or IV transition, and rescue plan with anesthesia and the prescribing team.[1][12]
  3. After uncomplicated recovery, return to the required baseline regimen after the agreed perioperative coverage; comparative studies assessed short-term hemodynamics under different perioperative doses, with postoperative tapers in both colorectal trial arms.[1][10][12]
  4. Keep hydrocortisone 100 mg IV available as a rescue for unexplained hypotension that does not respond to fluid or vasopressors, and consider adrenal insufficiency alongside hemorrhage and sepsis.[13]

The 2024 ESE/Endocrine Society guideline recommends stress coverage when current or recent at-risk glucocorticoid exposure leaves adrenal insufficiency unexcluded, including after a recent taper; for general or regional anesthesia, Table 8 describes induction dosing followed by 24-hour IV coverage and an oral transition. If a lower-dose protocol is chosen, document the reason and the perioperative plan.[1] Primary adrenal insufficiency and hypothalamic-pituitary disease are outside this shortcut and need the endocrine plan. Agree the approach with anesthesia and the prescribing team.

Urologic Quick Reference​

ScenarioApproach
Transplant recipient on prednisone 5 mg/day, elective reconstruction under general anesthesiaContinue the baseline dose. The ESE schedule gives hydrocortisone 100 mg IV at induction and 200 mg/24 h, then increased oral coverage for 48 hours.[1] A lower-dose alternative requires a documented anesthesia and transplant-team plan for perioperative dosing, oral transition and rescue.
IBD patient on prednisone 15 mg/day, cystectomy with diversionBaseline is above the 10 mg/day minor-stress threshold, but this is major stress with NPO. Use the NPO/long-recovery regimen unless the patient is at or above the prednisone 50 mg/day major-stress threshold and parenteral coverage remains reliable.[1]
Rheumatoid arthritis on prednisone 7.5 mg/day, pyeloplastyGeneral anesthesia, short recovery: Table 8 gives an induction bolus plus 24-hour infusion, then oral increase for 48 hours.[1] A lower-dose alternative requires a documented perioperative and postoperative dosing plan with reliable oral or IV replacement and rescue instructions.
Sling revision under local anesthesia in a patient at risk of or with diagnosed glucocorticoid-induced adrenal insufficiency taking prednisoneAlready at 10 mg/day or more: usually no increase. Below that: raise to prednisone 10 mg one hour before.[1]
Inhaled fluticasone for asthmaAssess daily dose, duration, recent systemic courses, concurrent steroid formulations and CYP3A4 inhibitors; fluticasone propionate and prolonged or high-dose inhaled treatment increase HPA-suppression risk.[1]
Unexplained postoperative shock with steroid historyHydrocortisone 100 mg IV or IM immediately; do not wait for testing.[1]

The transplant, IBD and rheumatoid rows follow Table 8 for adults at risk of glucocorticoid-induced adrenal insufficiency.[1] The alternative in the first and third rows is described under Where the Frameworks Disagree.

Perioperative Handoff​

Record the baseline indication and dose, adrenal-risk assessment, route while NPO, planned stress regimen, monitoring, oral transition and who will adjust the plan if complications occur.

References​

1. Beuschlein F, Else T, Bancos I, et al. European Society of Endocrinology and Endocrine Society joint clinical guideline: diagnosis and therapy of glucocorticoid-induced adrenal insufficiency. J Clin Endocrinol Metab. 2024;109:1657–1683. doi:10.1210/clinem/dgae250

2. Society for Endocrinology. Adrenal crisis information and emergency management. Official guidance.

3. National Institute for Health and Care Excellence. Adrenal insufficiency: identification and management. NG243, 2024. Recommendations, including section 1.7.

4. Corcoran TB, Myles PS, Forbes AB, et al. Dexamethasone and surgical-site infection. N Engl J Med. 2021;384:1731–1741. doi:10.1056/NEJMoa2028982

5. Wang AS, Armstrong EJ, Armstrong AW. Corticosteroids and wound healing: clinical considerations in the perioperative period. Am J Surg. 2013;206:410–417. doi:10.1016/j.amjsurg.2012.11.018

6. Adamina M, Kienle P, Chaparro M, et al. ECCO guidelines on therapeutics in ulcerative colitis: surgical treatment. J Crohns Colitis. 2026;20:jjag072. doi:10.1093/ecco-jcc/jjag072

7. Woodcock T, Barker P, Daniel S, et al. Guidelines for the management of glucocorticoids during the peri-operative period for patients with adrenal insufficiency: Guidelines from the Association of Anaesthetists, the Royal College of Physicians and the Society for Endocrinology UK. Anaesthesia. 2020;75(5):654-663. doi:10.1111/anae.14963

8. Goodman SM, Springer BD, Chen AF, et al. 2022 American College of Rheumatology/American Association of Hip and Knee Surgeons Guideline for the Perioperative Management of Antirheumatic Medication in Patients With Rheumatic Diseases Undergoing Elective Total Hip or Total Knee Arthroplasty. Arthritis Care Res (Hoboken). 2022;74(9):1399-1408. doi:10.1002/acr.24893

9. Freudzon L. Perioperative steroid therapy: where's the evidence? Curr Opin Anaesthesiol. 2018;31(1):39-42. doi:10.1097/ACO.0000000000000547

10. Marik PE, Varon J. Requirement of perioperative stress doses of corticosteroids: a systematic review of the literature. Arch Surg. 2008;143(12):1222-1226. doi:10.1001/archsurg.143.12.1222

11. Glowniak JV, Loriaux DL. A double-blind study of perioperative steroid requirements in secondary adrenal insufficiency. Surgery. 1997;121(2):123-129. doi:10.1016/s0039-6060(97)90280-4

12. Zaghiyan K, Melmed GY, Berel D, et al. A prospective, randomized, noninferiority trial of steroid dosing after major colorectal surgery. Ann Surg. 2014;259(1):32-37. doi:10.1097/SLA.0b013e318297adca

13. Coccolini F, Improta M, Sartelli M, et al. Acute abdomen in the immunocompromised patient: WSES, SIS-E, WSIS, AAST, and GAIS guidelines. World J Emerg Surg. 2021;16(1):40. doi:10.1186/s13017-021-00380-1

14. Modha K, Whinney C. Risks and management of glucocorticoid therapy for patients with rheumatic disease having surgery. Curr Rheumatol Rep. 2026;28(1):17. doi:10.1007/s11926-026-01221-3

15. Jones IA, LoBasso MA, Wier J, et al. "Perioperative Dexamethasone in Diabetic Patients: A Systematic Review and Meta-Analysis of Randomized, Placebo-Controlled Trials." Anesth Analg. 2024;139(3):479–489. doi:10.1213/ANE.0000000000007007

16. Dimmen A, Timko S, Greenwood J, McShane F, Ulinski J. "Effect of dexamethasone administration for postoperative nausea and vomiting prophylaxis on glucose levels in adults with diabetes undergoing elective surgery: a systematic review with meta-analysis." JBI Evid Synth. 2023;21(11):2156–2187. doi:10.11124/JBIES-22-00300