Postoperative Steroid Replacement After Adrenalectomy

Immediate Perioperative Management

The American Society of Anesthesiologists recommends administering hydrocortisone 100 mg IV at surgical induction, followed by a continuous infusion of hydrocortisone 200 mg/24h for patients undergoing adrenalectomy for Cushing syndrome 1, 2
The Endocrine Society suggests continuing hydrocortisone 200 mg/24h IV infusion while the patient is NPO or unable to tolerate oral intake, and transitioning to oral therapy once tolerating PO: hydrocortisone 30-50 mg daily in divided doses or prednisone 20 mg daily 1, 2, 3

The Journal of Clinical Oncology recommends using the equivalency ratio: 20 mg hydrocortisone = 5 mg prednisone, and initial oral replacement: prednisone 20 mg daily or hydrocortisone 50 mg daily (divided as 30 mg AM, 20 mg early afternoon) 3, 4
The guideline suggests tapering the dose gradually over weeks to months based on ACTH recovery, with a goal of reaching physiologic replacement of prednisone 5 mg daily (or hydrocortisone 15-20 mg daily) 3, 4

The American College of Endocrinology recommends monitoring for signs of under-replacement (fatigue, nausea, hypotension, hyponatremia, hyperkalemia) and over-replacement (bruising, thin skin, edema, weight gain, hypertension, hyperglycemia) during the taper period 3, 4
The Endocrine Society suggests checking morning ACTH and cortisol levels every 2-4 weeks during taper, and considering an ACTH stimulation test if cortisol levels are 3-15 mcg/dL to assess adrenal reserve 3

The American Association of Clinical Endocrinologists recommends lifelong glucocorticoid replacement for patients who have undergone bilateral adrenalectomy, and adding fludrocortisone 0.05-0.1 mg daily for mineralocorticoid replacement (primary adrenal insufficiency) 3, 4
The guideline suggests titrating fludrocortisone based on volume status, sodium, and renin (target upper half of reference range) 3, 4

The Journal of Clinical Oncology warns that 7% of patients on replacement therapy develop acute adrenal insufficiency during taper, and recommends educating patients on stress-dosing: double or triple maintenance dose during illness, injury, or stress 3, 4
The American College of Endocrinology suggests providing emergency injectable hydrocortisone and medical alert identification, and never abruptly discontinuing steroids—always tapering gradually 3, 4
The Endocrine Society recommends avoiding the use of dexamethasone for long-term replacement due to its lack of mineralocorticoid activity and potential for prolonged suppression 5