Low-dose perioperative steroids effective in IBD patients

Major finding: Low-dose corticosteroids are as effective as high dose in preventing postoperative postural hypotension or adrenal insufficiency in patients with inflammatory bowel disease.

Data source: Randomized, single-blinded noninferiority trial in 92 patients.

Disclosures: No conflicts of interest were declared.



Postoperative postural hypotension or adrenal insufficiency in patients with inflammatory bowel disease can be effectively prevented with low-dose rather than high-dose steroids, according to data published in the June 14 online issue of Annals of Surgery [doi: 10.1097/SLA.b013e318297adca].

"Corticosteroid-treated patients undergoing major colorectal surgery are commonly prescribed high-dose steroids to prevent perioperative adrenal insufficiency and cardiovascular collapse," wrote Dr. Karen Zaghiyan and her colleagues from Cedars-Sinai Medical Center, Los Angeles. "There is little evidence to support this practice."

A randomized, single-blinded noninferiority trial in 92 steroid-treated inflammatory bowel disease (IBD) patients undergoing major colorectal surgery showed that 96% of patients randomized to low-dose steroids and 95% of patients randomized to high-dose steroids did not exhibit postural hypotension on the first day after surgery (noninferiority 95% confidence interval, –0.08 to 0.09; P = .007).

"Because reports of postoperative adrenal insufficiency and hemodynamic collapse have implicated the first 24 hours after surgery as the most susceptible, and postural hypotension is likely to be a more reliable indicator of hemodynamic instability than supine hypotension, our primary endpoint was clinically meaningful," the researchers reported.

Patients were randomized to receive either 100 mg of IV hydrocortisone at the time of incision and three times daily for the first postoperative day, then tapered, or to low-dose IV hydrocortisone equivalent to presurgical oral dosing, followed by taper.

The primary outcome was the absence of postural hypotension on postoperative day 1, defined as a decrease in systolic blood pressure by 20 mm Hg after sitting from a supine position.

"We found no significant difference in perioperative factors, including operative time, intraoperative blood loss, volume of intravenous fluids administered, number of patients requiring intravenous fluid boluses, or blood transfusions between our two patient groups," the researchers reported.

The investigators also found no significant differences in other outcomes such as surgical or medical complications, length of postoperative stay, fatigue, nausea, and pain, although there was an insignificant trend toward more infectious complications in the high-dose steroid group.

The practice of administering high doses of corticosteroids perioperatively was sparked in the 1950s by two incidences of postoperative cardiovascular collapse and death in patients whose preoperative corticosteroids were discontinued before surgery, the authors said.

"However, high-dose corticosteroids are not without consequence and have been associated with various postoperative complications, including wound infection and anastomotic dehiscence," the authors reported.

Some studies had already suggested that steroid-treated patients undergoing surgery could remain on their baseline corticosteroid dose perioperatively; however, these studies were mostly focused on organ transplant recipients or included patients taking low maintenance doses of corticosteroids undergoing minor or moderate surgical procedures.

"Patients with IBD represent a unique study cohort because they are frequently taking high doses of steroids for a prolonged period of time, and surgery in these patients often involves major stress," the researchers reported.

"Although we recently published our retrospective data to suggest safety of low-dose steroids in steroid-treated IBD patients undergoing major colorectal surgery, this is the first prospective study to evaluate the role of stress-dose steroids in patients undergoing major abdominal and pelvic surgery," the investigators wrote.

There were no conflicts of interest declared.

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