A 56-year-old woman with colon cancer diagnosed on screening colonoscopy is scheduled for hemicolectomy in 2 weeks. She has a history of systemic lupus erythematosus, lupus nephritis, and pericarditis. The patient was treated with cyclophosphamide and high-dose corticosteroids for her lupus nephritis 6 years ago. The nephritis went into remission after 2 years of treatment and has not reoccurred. Six months ago, she had an episode of pericarditis with effusion that was treated with high-dose prednisone. The prednisone was slowly tapered and discontinued a week ago. She is currently on a maintenance regimen of hydroxychloroquine.
Blood pressure is 135/80 mm Hg and pulse is 82/min. Her body mass index is 29 kg/m². Lungs are clear to auscultation. There are no skin rashes or striae. She has a Cushingoid appearance. There is no peripheral edema.
Laboratory results are as follows:

Which of the following is the best next step in managing this patient's preoperative steroid requirement?

Question

A 56-year-old woman with colon cancer diagnosed on screening colonoscopy is scheduled for hemicolectomy in 2 weeks. She has a history of systemic lupus erythematosus, lupus nephritis, and pericarditis. The patient was treated with cyclophosphamide and high-dose corticosteroids for her lupus nephritis 6 years ago. The nephritis went into remission after 2 years of treatment and has not reoccurred. Six months ago, she had an episode of pericarditis with effusion that was treated with high-dose prednisone. The prednisone was slowly tapered and discontinued a week ago. She is currently on a maintenance regimen of hydroxychloroquine.
Blood pressure is 135/80 mm Hg and pulse is 82/min. Her body mass index is 29 kg/m². Lungs are clear to auscultation. There are no skin rashes or striae. She has a Cushingoid appearance. There is no peripheral edema.
Laboratory results are as follows:

Which of the following is the best next step in managing this patient's preoperative steroid requirement?

Quizplus · Accepted Answer

11ec193a_97ba_5005_853d_83cae9ff09b8_MD0002_00 Suppression of adrenal function is likely to develop in patients receiving corticosteroids for a prolonged period. This is especially true for those who receive high doses and those who are dosed at night rather than during the morning hours. In addition, patients with a Cushingoid appearance are more likely to have a suppressed hypothalamic-pituitary-adrenal (HPA) axis. Patients treated with corticosteroids for <3 weeks are less likely to develop HPA suppression. More importantly, normal HPA axis function after corticosteroid use may not fully recover for up to 6-12 months after discontinuation of the medication. During the recovery period, a patient may be asymptomatic under normal conditions but can develop adrenal crisis during stressful situations such as severe illness or surgery. This patient received a prolonged course of high-dose corticosteroids until a week ago, and she has a Cushingoid appearance. She likely has residual suppression of the HPA axis. Therefore, the most prudent approach is to treat her perioperatively with stress-dose corticosteroids. (Choice A) An ACTH (cosyntropin) stimulation test is performed to determine whether stress-dose corticosteroids are necessary in patients at intermediate risk for HPA axis suppression. If the patient has a subnormal increase in cortisol level following ACTH stimulation, stress-dose corticosteroids must be given perioperatively. (Choices B and C) During stressful states (eg, infection, trauma, surgery), the secretion of cortisol normally increases significantly. Patients with adrenal insufficiency undergoing significant stress, such as abdominal surgery, should be treated with stress-dose corticosteroids to prevent adrenal crisis. A typical perioperative corticosteroid regimen for a major surgical procedure is hydrocortisone 100 mg intravenously during surgery followed by 50 mg every 8 hours for 24 hours with a rapid taper (generally 1-2 days) as the stress resolves. Educational objective: Patients treated with corticosteroids for >3 weeks are likely to develop suppression of the hypothalamic-pituitary-adrenal (HPA) axis. Patients with a Cushingoid appearance have a higher likelihood of HPA suppression. HPA axis suppression from corticosteroid use may not resolve for up to 6-12 months after discontinuation of the medication. __________ References: Management of adrenal insufficiency during the stress of medical illness and surgery. (http://www.ncbi.nlm.nih.gov/pubmed/18393745) Adrenal insufficiency in high-risk surgical ICU patients. (http://www.ncbi.nlm.nih.gov/pubmed/11243973) Perioperative management of patients treated with glucocorticoids. (http://www.ncbi.nlm.nih.gov/pubmed/12800537)

A 56-Year-Old Woman with Colon Cancer Diagnosed on Screening Colonoscopy