Management of Perioperative Glucocorticoids in Patients with Rheumatic Conditions
Rationale for Continuing Current Glucocorticoid Dose
- The American College of Rheumatology/American Association of Hip and Knee Surgeons guidelines conditionally recommend continuing the current daily dose of glucocorticoids rather than administering supraphysiologic "stress doses" for patients with rheumatic conditions undergoing total knee arthroplasty 1
- This recommendation specifically applies to patients receiving ≤16 mg/day prednisone equivalent for their rheumatic condition 2, 3
- Evidence from observational trials and systematic reviews suggests no significant hemodynamic difference between patients given their current daily glucocorticoid dose compared to those receiving stress-dose steroids 3
No Need for Morning Cortisol Testing
- For patients on chronic glucocorticoid therapy for rheumatic conditions, there is no recommendation to check morning serum cortisol levels prior to elective orthopedic surgery 1, 2
- The Centers for Disease Control and Prevention considers the cutoff for immunosuppression at 20 mg of prednisone/day for at least 2 weeks 2
- Checking cortisol levels would not change management in this scenario as the patient should continue their usual dose regardless 1, 3
Infection Risk Considerations
- Observational studies demonstrate an increase in arthroplasty infection risk with long-term steroid use >15 mg/day 2
- At 10 mg daily, this patient is below both thresholds, making them an appropriate candidate for elective surgery without additional intervention 2, 3
Polymyalgia Rheumatica Management Context
- Polymyalgia rheumatica typically requires glucocorticoid therapy, with most patients needing between 5-20 mg of prednisone daily for symptom control 4
Postoperative Considerations
- The patient should resume their usual 10 mg daily dose of prednisone immediately after surgery 1, 3
- Monitor for signs of disease flare or adrenal insufficiency in the postoperative period 4