From Clinic to Recovery · First Edition
Chapter 21 — Corticosteroids and Other Immunosuppressive Medicines
Dr. Tamer Rushdy Elalfy · 11 min read
In this chapter
Corticosteroids are among the most widely used medicines, for asthma, arthritis, inflammatory bowel disease, skin conditions, and many others. Patients who take them for weeks or longer may not be able to produce enough of their own cortisol under the stress of surgery, and can develop an adrenal crisis: a sudden, life-threatening drop in blood pressure. Steroids also slow wound healing and increase infection. Many patients do not think of inhalers, creams, joint injections, or a course that finished recently as “steroids,” so careful questioning is essential. This chapter explains how to identify patients at risk, how to give steroid cover, and how to teach patients to protect themselves.
Learning objectives After reading this chapter you should be able to:
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Table 21.1. Corticosteroids and surgery at a glance.
| At a glance | |
|---|---|
| Patients at risk | Known adrenal insufficiency, or prednisolone 5 mg or more a day (or equivalent) for 4 weeks or more, by any route |
| Day of surgery | Take the usual morning dose; give extra hydrocortisone according to the type of surgery |
| After surgery | Continue cover while nil by mouth; then double the usual oral dose for a period before returning to normal |
| Adrenal crisis | Low blood pressure, vomiting, abdominal pain, confusion: hydrocortisone 100 mg IV or IM at once |
| The key counseling message | “Never stop your steroid suddenly, and always tell every doctor and nurse that you take it.” |
STEP 1 Identifying risk and explaining the plan
21.1 Who is at risk
Patients with primary or secondary adrenal insufficiency are at high risk of adrenal crisis around surgery. In addition, a daily dose of prednisolone of 5 mg or more, or its equivalent, taken for 4 weeks or more, may suppress the body’s own cortisol production, whether taken by mouth or by inhaled, intranasal, intra-articular, or topical routes [1]. Patients who have recently stopped long-term steroids may still be at risk, and the 2024 European and Endocrine Society guideline gives detailed advice on assessment [2]. Table 21.2 shows approximate equivalent doses.
Table 21.2. Approximate equivalent glucocorticoid doses.
| Steroid | Dose approximately equal to prednisolone 5 mg |
|---|---|
| Prednisolone | 5 mg |
| Hydrocortisone | 20 mg |
| Methylprednisolone | 4 mg |
| Dexamethasone | 0.75 mg |
Script: asking about steroids “Do you take any steroid tablets, or have you taken a course in the last year? Do you use steroid inhalers, nasal sprays, or strong creams, or have you had steroid injections into a joint?” “Because you have been taking steroids for some time, your body may not make enough of its own steroid during the stress of an operation. We will give you extra steroid around the operation to keep you safe.” |
21.2 Steroid cover for surgery
Patients at risk should take their usual steroid dose on the morning of surgery and receive additional hydrocortisone according to the type of procedure (Figure 21.1). For major surgery, the 2020 UK guideline recommends hydrocortisone 100 mg intravenously at induction, followed by 200 mg over 24 hours by infusion, or 50 mg every 6 hours, while the patient is nil by mouth or vomiting, and then double the usual oral dose for 48 hours or up to a week before returning to the usual dose [1]. For body surface and intermediate surgery, the same induction dose is followed by double the usual oral dose for 48 hours [1]. Endocrinology advice should be sought for patients with primary adrenal insufficiency, very high doses, or complex courses.
[Figure — diagram omitted in this text edition; see the figure caption below and the Word chapter file for the image]
Figure 21.1. Steroid cover for surgery in patients at risk of adrenal insufficiency.
Guidance differs for some groups. A 2022 rheumatology guideline for hip and knee replacement advises continuing the usual daily steroid dose, rather than giving extra stress doses, in patients taking steroids for rheumatic diseases who do not have known adrenal insufficiency [3]. Each hospital should agree one approach with its endocrinology and anesthesia teams.
21.3 Adrenal crisis
Caution: recognizing and treating adrenal crisis
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21.4 Wound healing and other immunosuppressive medicines
Long-term steroids slow wound healing, thin the skin, and increase infection. Reduce the dose before elective surgery only with the prescribing specialist, never abruptly. Other immunosuppressive medicines, such as methotrexate, biologic therapies for arthritis or inflammatory bowel disease, and transplant medicines, need an individual plan with the prescribing specialist; some are continued, and some are paused for one dosing cycle before planned surgery [3]. Transplant medicines should never be stopped without specialist advice.
STEP 2 Recovery, sick-day rules, and Ramadan
21.5 After surgery and at home
- Hospital. Continue intravenous hydrocortisone while the patient is nil by mouth or vomiting, then double the oral dose as planned.
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Discharge. Give a written plan for when to return to the usual dose, and check that the patient has a steroid emergency card [4].
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Sick-day rules. If the patient develops a fever, an infection, or another illness needing bed rest, they should double their usual steroid dose and seek advice; if they are vomiting and cannot keep tablets down, they need an injection and urgent medical care.
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Wounds. Check wounds closely; healing may be slower.
21.6 Ramadan
Patients who take steroid replacement for adrenal insufficiency are at higher risk when fasting and should discuss fasting with their endocrinologist, who may adjust the timing or type of steroid. No patient should fast while recovering from surgery or while unwell.
STEP 3 Questions patients ask
“Why do I need extra steroid for the operation?”
Your body may not make enough of its own steroid under the stress of surgery, because you have taken steroids for some time. Extra steroid keeps your blood pressure safe [1].
“Should I take my steroid on the morning of surgery?”
Yes. Never miss it. We will give you extra on the day.
“I use a steroid inhaler. Does that count?”
It can, especially at higher doses. Tell us about all inhalers, nasal sprays, creams, and joint injections [1].
“Will steroids affect my wound?”
They can slow healing and increase infection. We check your wound closely; do not reduce your dose yourself.
“What is a steroid emergency card?”
A card that tells any doctor that you take steroids and may need an urgent injection if you are very unwell. Carry it at all times [4].
“What should I do if I get sick at home?”
If you have a fever or infection, double your steroid dose and call your doctor. If you are vomiting and cannot keep tablets down, go to the emergency department at once and show your card.
“Can I fast in Ramadan?”
Not while recovering from surgery. If you take steroid replacement for adrenal insufficiency, discuss fasting with your endocrinologist first.
STEP 4 Risks, warning signs, and consent
21.7 Additional risks
Table 21.3. Additional risks for patients taking steroids. Square brackets mark figures to replace with unit data.
| Band | Risk | Typical frequency | Example wording |
|---|---|---|---|
| Less common | Wound infection or slow healing | Higher than in patients not taking steroids [unit data] | “Steroids can slow healing.” |
| Less common | High blood glucose from extra steroid | [unit data] | “Your sugar may rise for a few days.” |
| Rare but serious | Adrenal crisis | [unit data] | “Without extra steroid, blood pressure can fall dangerously. This is why we give cover.” |
21.8 Checklist
Before surgery ☐ All steroid use asked about, including inhaled, nasal, topical, injected, and recent courses. ☐ Risk of adrenal insufficiency assessed; steroid cover plan written in the notes and anesthesia chart. ☐ Usual morning dose to be taken on the day of surgery. ☐ Other immunosuppressants planned with the prescribing specialist. ☐ Steroid emergency card checked or issued; sick-day rules taught with teach-back. |
21.9 Warning signs
Table 21.4. Green, amber, and red warning signs for patients taking steroids.
| Level | Signs | What to do |
|---|---|---|
| Green | Tiredness for a few days after surgery | Expected. Take your steroids exactly as planned. |
| Amber | Fever or infection A wound that is red, warm, or leaking | Double your steroid dose if advised, and call your doctor today. |
| Red | Vomiting and unable to keep tablets down Dizziness or fainting, severe weakness, abdominal pain, or confusion | Go to the emergency department now. Show your steroid emergency card. |
Key points
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STEP 5 Patient education guide
The following pages may be photocopied and given to patients. Complete the steroid plan with the patient, and add your unit’s name, phone numbers, and review date before use.
PATIENT GUIDE Steroid Medicines and Your Operation Keep this with your steroid emergency card. |
Why steroids matter for your operation
If you have taken steroids for some time, your body may not make enough of its own steroid during an operation or illness. This can make your blood pressure fall dangerously. Extra steroid around the operation keeps you safe.
My steroid plan
| What to take | |
|---|---|
| My usual steroid and dose | |
| Morning of surgery | Take your usual dose. Do not miss it. |
| In hospital | Extra steroid given by the team |
| After going home | Double dose for ______ days, then back to usual dose |
Golden rules
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Never stop your steroid suddenly.
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Tell every doctor, nurse, and dentist that you take steroids.
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Carry your steroid emergency card at all times.
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Tell us about inhalers, nasal sprays, creams, and joint injections too.
If you are ill at home: sick-day rules
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Fever or infection: double your steroid dose and call your doctor.
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Vomiting and cannot keep tablets down: go to the emergency department now and show your card. You need an injection.
Ramadan
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Do not fast while recovering from surgery or while unwell.
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If you take steroid replacement, ask your endocrinologist before fasting.
Warning signs: when to get help
| Level | What you notice | What to do |
|---|---|---|
| GREEN | Tiredness for a few days | Take your steroids as planned. |
| AMBER | Fever or infection; a red or leaking wound | Double your dose if advised, and call your doctor today. |
| RED | Vomiting and cannot keep tablets down; dizzy or fainting; severe weakness; tummy pain; confusion | Go to the emergency department now. Show your steroid card. |
My contacts Surgical team: ______________________ Endocrinologist: ______________________ Out of hours: ______________________ [Unit name] [Guide version and review date] |
References
1. 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.
2. 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. Eur J Endocrinol. 2024;190(5):G25-G51.
3. 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 Rheumatol. 2022;74(9):1464-1473.
4. NHS England and NHS Improvement. National Patient Safety Alert: Steroid Emergency Card to support early recognition and treatment of adrenal crisis in adults. NatPSA/2020/005/NHSPS. August 2020.
Note: references are numbered within this chapter for the pilot. Items marked in square brackets are collected in the Author Fill-in and Verification Log.