Perioperative management of patients treated with glucocorticoids

2022 Chinese guideline for the management of pregnancy and reproduction in systemic lupus erythematosus

Systemic lupus erythematosus (SLE), a prevalent autoimmune disease predominantly affecting women of childbearing age, presents ongoing challenges despite notable advances in diagnosis and treatment. Although survival rates for SLE patients have significantly improved, pregnancy continues to pose a considerable obstacle. Addressing this critical need for enhanced reproductive and prenatal care, there is a pressing imperative to establish standardized protocols for peri-gestational monitoring and treatment in SLE patients. This guideline is jointly sponsored by the National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), the Chinese Systemic Lupus Erythematosus Treatment and Research Group (CSTAR), and the Chinese Research Committee of Pregnancy and Reproduction in Autoimmune Rheumatic Diseases (CHOPARD). Thirteen pertinent clinical questions have been generated through several rounds of rigorous clinical and methodological expert discussions and selections for a comprehensive understanding of key aspects in this domain. Guided by thorough examination of research evidence and expert perspectives, the formulated recommendations aim to optimize pregnancy success rates, reduce maternal and infant mortality rates, and ultimately enhance the overall well-being of SLE patients.

Perioperative Evaluation and Management of Patients on Glucocorticoids

Myriad questions regarding perioperative management of patients on glucocorticoids (GCs) continue to be debated including which patients are at risk for adrenal insufficiency (AI), what is the correct dose and duration of supplemental GCs, or are they necessary for everyone? These questions remain partly unanswered due to the heterogeneity and low quality of data, studies with small sample sizes, and the limited number of randomized trials. To date, we know that although all routes of GC administration can result in hypothalamic-pituitary-adrenal (HPA) axis suppression, perioperative adrenal crisis is rare. Correlation between biochemical testing for AI and clinical events is lacking. Some of the current perioperative management recommendations based on daily GC dose and duration of therapy may be difficult to follow in clinical practice. The prospective and retrospective studies consistently report that continuing the daily dose of GCs perioperatively is not associated with a higher risk for adrenal crises in patients with GC-induced AI. Considering that oral GC intake may be unreliable in the early postoperative period, providing the daily GC plus a short course of IV hydrocortisone 25 to 100 mg per day based on the degree of surgical stress seems reasonable. In patients who have stopped GC therapy before surgery, careful assessment of the HPA axis is necessary to avoid an adrenal crisis. In conclusion, our literature review indicates that lower doses and shorter duration of supplemental GCs perioperatively are sufficient to maintain homeostasis. We emphasize the need for well-designed randomized studies on this frequently encountered clinical scenario.

The American Association of Endocrine Surgeons Guidelines for the Definitive Surgical Management of Secondary and Tertiary Renal Hyperparathyroidism

OBJECTIVE

To develop evidence-based recommendations for safe, effective, and appropriate treatment of secondary (SHPT) and tertiary (THPT) renal hyperparathyroidism.

BACKGROUND

Hyperparathyroidism is common among patients with chronic kidney disease, end-stage kidney disease, and kidney transplant. The surgical management of SHPT and THPT is nuanced and requires a multidisciplinary approach. There are currently no clinical practice guidelines that address the surgical treatment of SHPT and THPT.

METHODS

Medical literature was reviewed from January 1, 1985 to present January 1, 2021 by a panel of 10 experts in SHPT and THPT. Recommendations using the best available evidence was constructed. The American College of Physicians grading system was used to determine levels of evidence. Recommendations were discussed to consensus. The American Association of Endocrine Surgeons membership reviewed and commented on preliminary drafts of the content.

RESULTS

These clinical guidelines present the epidemiology and pathophysiology of SHPT and THPT and provide recommendations for work-up and management of SHPT and THPT for all involved clinicians. It outlines the preoperative, intraoperative, and postoperative management of SHPT and THPT, as well as related definitions, operative techniques, morbidity, and outcomes. Specific topics include Pathogenesis and Epidemiology, Initial Evaluation, Imaging, Preoperative and Perioperative Care, Surgical Planning and Parathyroidectomy, Adjuncts and Approaches, Outcomes, and Reoperation.

CONCLUSIONS

Evidence-based guidelines were created to assist clinicians in the optimal management of secondary and tertiary renal hyperparathyroidism.

Peri-operative steroid management in the paediatric population

BACKGROUND

Patients with adrenal insufficiency are at risk of adrenal crisis, a potentially life-threatening emergency in the peri-operative period due to their attenuated ability to mount a cortisol response. There is a lack of standardization regarding peri-operative stress-dose glucocorticoids in paediatric clinical practice with the absence of agreed protocols. For the individual patient, the risk of adrenal crisis must be weighed against the potential adverse clinical outcomes associated with unnecessary or supra-physiologic glucocorticoid dosing in susceptible patients. Specific clinical concerns in the paediatric population include osteopenia, growth restriction and increased risk of cardiovascular disease in adulthood. This review aimed to identify and evaluate available literature in the field of peri-operative stress-dose glucocorticoids.

METHODS

A comprehensive literature search was conducted to construct a narrative review.

RESULTS

The outcome of this review identified that paediatric patients, unlike adults, do not show a graded response to surgical stress with implications for glucocorticoid stress dose regimens for general anaesthesia and less invasive surgical procedures. The studies highlight a lack of information on physiological steroid responses to stress situations and differences in the approach to glucocorticoid replacement strategies in the paediatric population.

CONCLUSION

The review identified there is a lack of high-quality paediatric-specific studies evaluating appropriate stress-dose glucocorticoid regimens in paediatric patients with or at risk of adrenal insufficiency. Further research is needed to establish clear evidence-based clinical guidelines for paediatric peri-operative practice regarding steroid stress dosing in adrenal insufficiency. Current knowledge would suggest that a balanced view of risks and benefits should be taken appropriate to the clinical context, to dictate peri-operative stress-dose glucocorticoids use that permits safe perioperative management.

Perioperative glucocorticoid management based on current evidence

Glucocorticoid preparations, adreno-cortical steroids, with strong anti-inflammatory and immunosuppressive effects, are widely used for treating various diseases. The number of patients exposed to steroid therapy prior to surgery is increasing. When these patients present for surgery, the anesthesiologist must decide whether to administer perioperative steroid supplementation. Stress-dose glucocorticoid administration is required during the perioperative period because of the possibility of failure of cortisol secretion to cope with the increased cortisol requirement due to surgical stress, adrenal insufficiency, hemodynamic instability, and the possibility of adrenal crisis. Therefore, glucocorticoids should be supplemented at the same level as that of normal physiological response to surgical stress by evaluating the invasiveness of surgery and inhibition of the hypothalamus-pituitary-adrenal axis. Various textbooks and research articles recommend the stress-dose of glucocorticoids during perioperative periods. It has been commonly suggested that glucocorticoids should be administered in an amount equivalent to about 100 mg of cortisol for major surgery because it induces approximately 5 times the normal secretion. However, more studies, with appropriate power, regarding the administration of stress-dose glucocorticoids are still required, and evaluation of patients with possible adrenal insufficiency and appropriate glucocorticoid administration based on surgical stress will help improve the prognosis.

Different Potent Glucocorticoids, Different Routes of Exposure but the Same Result: Iatrogenic Cushing’s Syndrome and Adrenal Insufficiency

OBJECTIVE

Potent glucocorticoids (GC) cause iatrogenic Cushing’s syndrome (ICS) due to suppression of hypothalamo-pituitary-adrenal (HPA) axis and may progress to adrenal insufficiency (AI). The aim was to review the clinical and laboratory findings of patients with ICS and to investigate other serious side effects.

METHODS

The possibility of AI was investigated by low-dose adrenocorticotrophic hormone test. Hydrocortisone was started in patients with adrenal failure.

RESULTS

Fourteen patients (five boys) with ages ranging from 0.19 to 11.89 years were included. The duration of GC exposure ranged from 1 to 72 months. Ten patients were prescribed topical GC and the rest had oral exposure. Moon face and abdominal obesity were detected in all patients. At presentation, 12 of 14 had AI and two infants had hypercalcemia and nephrocalcinosis. Of 11 patients, ultrasonography revealed hepatosteatosis in five. A cream for diaper dermatitis was used in one infant and the active ingredient was listed as panthenol. However, blood and urine steroid analyses revealed that all endogenous steroids were suppressed. Median (range) time to normalization of HPA axis function was 60 (30-780) days.

CONCLUSION

The majority (85%) of patients had life-threatening AI and two patients had hypercalcemia. These results highlight the serious side-effects of inappropriate use of potent GCs, especially in infants. The recovery of the HPA axis in children might take as long as three years. Parents should be informed regarding the possibility of some products containing unlisted synthetic GC and to be aware of their side effects.

The Historical Role and Contemporary Use of Corticosteroids in Inflammatory Bowel Disease

The use of corticosteroids to treat patients with inflammatory bowel disease [IBD] has been the bedrock of IBD therapeutics since the pioneering work of Truelove and Witts in the UK in the 1950s and subsequent large cohort studies in the USA and Europe. Nevertheless, although effective for induction of remission, these agents do not maintain remission and are associated with a long list of recognised side effects, including a risk of increased mortality. With the arrival of an increasing number of therapies for patients with IBD, the question arises as to whether we are using these agents appropriately in contemporary practice. This review discusses the historical background to steroid usage in IBD, and also provides a brief review of the literature on side effects of corticosteroid treatment as relevant to IBD patients. Data on licensed medications are presented with specific reference to the achievement of corticosteroid-free remission. We review available international data on the incidence of corticosteroid exposure and excess, and discuss some of the observations we and others have made concerning health care and patient-level factors associated with the risk of corticosteroid exposure, including identification of 'at-risk' populations.

Oral corticosteroids for asthma exacerbations might be associated with adrenal suppression: Are physicians aware of that?

INTRODUCTION

Oral corticosteroids (OCS) are a mainstay of treatment for asthma exacerbations, and short-term OCS courses were generally considered to be safe. Nevertheless, frequent short-term OCS courses could lead to hypothalamic-pituitary-adrenal (HPA) axis dysfunction. Our study aimed at investigating the integrity of the HPA axis in children with persistent asthma or recurrent wheezing at the beginning of an inhaled corticosteroids (ICS) trial.

METHOD

Morning basal cortisol was assessed just before the beginning of ICS, and 30, 60, and 90 days later, using Immulite® Siemens Medical Solutions Diagnostic chemiluminescent enzyme immunoassay (Los Angeles, USA; 2006).

RESULTS

In all, 140 children (0.3-15 years old) with persistent asthma or recurrent wheezing have been evaluated and 40% of them reported short-term OCS courses for up to 30 days before evaluation. Out of these, 12.5% had biochemical adrenal suppression but showed adrenal recovery during a three-month ICS trial treatment. No significant differences were observed among children with or without adrenal suppression, neither in the number of days free of OCS treatment before cortisol evaluation (p=0.29) nor in the last OCS course duration (p=0.20). The number of short-term OCS courses reported in the year preceding the cortisol evaluation was also not different (p=0.89).

CONCLUSION

Short-term systemic courses of corticosteroids at conventional doses can put children at risk of HPA axis dysfunction. ICS treatment does not impair adrenal recovery from occurring. Health practitioners should be aware of the risk of a blunted cortisol response upon exposure to stress during the follow-up of patients with persistent asthma or recurrent wheezing.

An Approach to Minimising Risk of Adrenal Insufficiency When Discontinuing Oral Glucocorticoids

Oral glucocorticoids are commonly used across every field of medicine; however, discontinuing them in patients can be challenging. The risk of acute adrenal crises secondary to glucocorticoid withdrawal can be fatal and arises from chronic suppression of the adrenal glands. Identifying risk factors for adrenal suppression in dermatological patients, such as doses greater than 5 to 7.5 mg of prednisone equivalent, duration of glucocorticoid use greater than 3 weeks, certain medications, and comorbidities, can help risk-stratify patients. The use of adrenal gland testing such as basal cortisol levels and adrenocorticotropic hormone stimulation tests can confirm adrenal suppression in patients. This review article provides an approach that dermatologists can use to minimise the risk of adrenal insufficiency in patients discontinuing glucocorticoids and when it may be appropriate to use adrenal gland testing.

Perioperative Steroid Management

Perioperative stress-dose steroid administration remains a controversial topic, with recent studies questioning its necessity. We discuss the current literature, largely published in nonanesthesiology journals, and suggest a practical approach to perioperative steroid management.

Perioperative management of drugs commonly used in patients with rheumatic diseases: a review

Rheumatic diseases are very prevalent, affecting about 7 million people in North America; they affect the musculoskeletal system, often with systemic involvement and potential for serious consequences and limitation on quality of life. Clinical treatment is usually long-term and includes drugs that are considered either simple or complex and are occasionally unknown to many health professionals who do not know how to manage these patients in emergency units and surgical wards. Thus, it is important for clinicians, surgeons and anesthesiologists who are involved with rheumatic patients undergoing surgery to know the basic principles of therapy and perioperative management. This study aims to do a review of the perioperative management of the most commonly used drugs in rheumatologic patients. Manuscripts used in this review were identified by surveying MEDLINE, LILACS, EMBASE, and COCHRANE databases and included studies containing i) the perioperative management of commonly used drugs in patients with rheumatic diseases: and ii) rheumatic diseases. They are didactically discussed according to the mechanism of action and pharmacokinetics; and perioperative management. In total, 259 articles related to the topic were identified. Every medical professional should be aware of the types of drugs that are appropriate for continuous use and should know the various effects of these drugs before indicating surgery or assisting a rheumatic patient postoperatively. This information could prevent possible complications that could affect a wide range of patients.

Patient optimization for surgery relating to Crohn's disease

The majority of patients with Crohn's disease require abdominal surgery during their lifetime, some of whom will require multiple operations. Postoperative complications are seen more frequently in patients requiring abdominal surgery for Crohn's disease than in patients requiring abdominal surgery for other conditions. In this article, we review the evidence supporting preoperative optimization, discussing strategies that potentially improve surgical outcomes and reduce perioperative morbidity and mortality. We discuss the roles of adequate cross-sectional imaging, nutritional optimization, appropriate adjustments of medical therapy, management of preoperative abscesses and phlegmons, smoking cessation and thromboembolic prophylaxis. We also review operation-related factors, and discuss their potential implications with respect to postoperative complications. Overall, the literature suggests that preoperative management has a major effect on postoperative outcomes.

The Steroids In the Maintenance of remission of Proliferative Lupus nephritis (SIMPL) pilot trial

Background

Patients with proliferative lupus nephritis are at risk of frequent relapses. Whether low- dose prednisone prevents relapses is uncertain.

Objectives

We undertook a pilot RCT to determine the feasibility of a larger trial.

Design

Pilot randomized controlled trial.

Setting

Single center Canadian outpatient nephrology clinic.

Patients

Participants with systemic lupus erythematosus (SLE) and a history of class III or IV lupus nephritis that achieved at least partial remission and remained on prednisone were eligible.

Measurements

Feasibility: proportion of eligible patients randomized and adherence to tapering regimen. Clinical: occurrence of renal or major non-renal flare of SLE.

Methods

We conducted a blinded, two-parallel-group randomized controlled trial of prednisone 7.5 mg/day (continuation) compared to a matching placebo (withdrawal).

Results

Of nineteen eligible patients screened, 15 (79%) were recruited and randomized; 8 to prednisone continuation and seven to withdrawal. All participants adhered to the tapering protocol to their assigned withdrawal or low-dose maintenance target. Over 36 months, the primary outcome occurred in four (50%) patients in the continuation group (three renal and one major non-renal flare), compared with one patient (14%) in the withdrawal group (one renal flare). Three participants (38%) in the continuation group had minor flares, while no patients in the withdrawal group did.

Limitations

This pilot RCT was small and not designed to assess the efficacy or safety of maintenance with low-dose prednisone.

Conclusions

The high proportion of eligible patients recruited, and success of protocol adherence suggest a large trial of prednisone maintenance therapy compared to withdrawal is feasible.

Trial registration

Current Controlled Trials ISRCTN31327267.

Bariatric surgery outcomes in patients with systemic lupus erythematosus

BACKGROUND

Obesity is common among systemic lupus erythematosus (SLE) patients. An increased perioperative risk after major surgery in SLE has been reported. The aim of this study was to describe postoperative outcomes among SLE patients undergoing bariatric surgery.

METHODS

Charts were reviewed to identify patients with an active diagnosis of SLE before bariatric surgery. Demographic variables, perioperative data, and SLE-related parameters were extracted.

RESULTS

Thirty-one morbidly obese patients who underwent bariatric surgery between 2005 and 2013 had a SLE diagnosis. Twenty-three patients had laparoscopic Roux-en-Y gastric bypass (RYGBP), 3 underwent laparoscopic revisional surgery for failed bariatric procedure, 3 had laparoscopic sleeve gastrectomy and 1 underwent laparoscopic adjustable gastric banding. Mean age, body mass index, and excess weight (kg) at baseline were 52.8±9.4 years, 44.3±9 kg/m(2), and 52.5±25.7 kg, respectively. Of these 31 patients, 24 (77.4%) were taking immunosuppressive medications at the time of surgery. Early major postoperative complications occurred in 4 patients (12.9%), with 3 requiring reoperation (9.6%). Multivariate analysis identified immunosuppressive therapy to be significantly associated with postoperative complications (P = .05). At a mean follow-up of 3 years, 13 patients (42%) showed reduction in the number of immunosuppressive medications and 6 (19.3%) were off steroids completely. After bariatric surgery, mean body mass index decreased to 34.2±8.2 kg/m(2) (P<.005) and excess weight loss was 51.2%± 33.4%.

CONCLUSION

Results suggest that weight loss after bariatric surgery is associated with decreased SLE immunosuppression medication requirements; however, the risks are higher. Bariatric surgery in this patient population should be approached with caution.

Pre-admission use of glucocorticoids and 30-day mortality following colorectal cancer surgery: a population-based Danish cohort study

BACKGROUND

Previous studies indicate that pre-admission glucocorticoids increase the risk of perioperative complications.

AIM

To examine whether pre-admission use of glucocorticoids affects 30-day mortality after colorectal cancer (CRC) surgery.

METHODS

We conducted a nationwide population-based cohort study by linking Danish medical registries. All residents in Denmark who underwent CRC surgery from 2001 to 2011 were included. We characterised subjects who filled their most recent glucocorticoid prescription ≤90, 91-365 and >365 days before their surgery date as prevalent, recent and former users, respectively. Prevalent users were subgrouped into new (first-ever prescription ≤90 days before surgery date) and continuing users. We estimated 30-day cumulative mortality by the Kaplan-Meier method and corresponding mortality rate ratios (MRRs) using Cox proportional hazard regression, adjusting for potential confounders.

RESULTS

Of the 34 641 CRC patients included, 3966 (11.5%) had filled one or more prescriptions of glucocorticoids within the year before the surgery date. Thirty-day mortality among prevalent users of oral glucocorticoids was 15.0% vs. 7.3% among non-users [MRR = 1.28; 95% confidence interval (CI): 1.03, 1.58]. Among new users, the 30-day mortality was 17.8% (MRR = 1.92; 95% CI: 1.30, 2.83) while it was 14.2% among continuing users (MRR = 1.13; 95% CI: 0.88, 1.44). No associations were found for recent or former use of oral glucocorticoids nor for use of inhaled, intestinal-acting, and mixed glucocorticoids.

CONCLUSIONS

Prevalent use, particulary new use, of oral glucocorticoids was associated with markedly increased 30-day mortality after colorectal cancer surgery compared to patients not exposed to any glucocorticoids.

Patients with chronic endocrine disease

This article summarizes the key features and clinical considerations related to preoperative management and planning for the care of patients of common endocrine disorders (diabetes mellitus, adrenal insufficiency, thyroid disease), a less common disorder but one that has significant perioperative implications (acromegaly), and 2 disorders for which preoperative management is essential to good postoperative outcomes (pheochromocytoma and carcinoid syndrome). There are few evidence-based guidelines for preoperative management of chronic endocrine disease; hence, this review is based on recent subspecialty society consensus guidelines and professional society clinical practice recommendations.

Perioperative assessment of the cancer patient

The perioperative evaluation of patients with cancer differs from that of other patients in that the former may have received prior chemotherapy or radiation therapy. These cancer treatments have a wide range of side effects and complications that may affect patients' perioperative risks. The perioperative specialist who evaluates the cancer patient prior to surgery must be familiar with the effects of these treatments and their consequences for the major organ systems. The perioperative specialist must also be familiar with the natural history of cancer and have a basic understanding of how cancer affects the body. In this article, we review the perioperative concerns that are specific to the patient with cancer.

[Evaluation of the prescription of long-term systemic steroid-therapy associated measures]

INTRODUCTION

To prevent the occurrence of corticosteroid's side effects, adjuvant measures are prescribed in a very different way depending on the practitioner's experience. The aim of this study was to assess the physicians' practices regarding the prescription of long-term corticosteroid therapy.

METHODS

In May 2010, we realized a cross-sectional study among physicians in Ibn Sina University Hospital in Rabat. With a data collection form, we assessed the principal indications for prescribing steroids and the frequency of prescription of measures sometimes associated with systemic corticosteroid.

RESULTS

Fifty-nine out of eighty physicians completed the data collection form (response rate: 69.4%). Calcium-vitamin D supplementation was recommended by most of the physicians. Half of them were prescribing biphosphonate therapy. Most of them propose a low-sodium, a low-fat and a low-carbohydrate dietary regimen. Regular physical exercise was recommended by 35% of physicians. Gastric protection was indicating by 54.4% of practicians and potassium supplementation by 42.1% of them. Finally, the recommendation for influenza vaccination, hydrocortisone prescription and Synacthen(®) test, varied between physicians.

CONCLUSION

The prescription of adjuvant measures with a long-term corticosteroid therapy was very heterogeneous. There is no consensus regarding most of the measures.

Are High-Dose Perioperative Steroids Necessary in Patients Undergoing Colorectal Surgery Treated with Steroid Therapy Within the Past 12 Months?

Patients previously on corticosteroids within 1 year before surgery are routinely treated with perioperative high-dose corticosteroids. However, there is little evidence to support this practice. We postulated that patients off steroids but treated with corticosteroids within 1 year before surgery may be safely managed without perioperative steroids. A chart review was performed on patients with inflammatory bowel disease (IBD) treated with corticosteroids within 1 year before surgery. Patients received either perioperative high-dose steroids (HDS) or no steroids (NS). Perioperative vital signs were assessed. Forty-nine operations were performed. Eleven patients received HDS and 38 patients received NS. Aside from a higher incidence of tachycardia (heart rate greater than 100 beats/min) in the HDS group (82%) compared with the NS group (42%), there was no significant difference in hemodynamic instability between the two groups. One patient in the NS group required a single dose of intraoperative vasopressor after aggressive beta-blockade. All other episodes of hemodynamic instability resolved with no intervention, fluid boluses, or blood transfusion. No patients required rescue high-dose steroids for adrenal insufficiency. In patients with IBD undergoing major colorectal surgery, treated with corticosteroids within the past year, management without perioperative steroids seems safe. A prospective study assessing perioperative corticosteroid dosing is in progress.

Clinical approach to adrenal insufficiency in hospitalised patients

Primary adrenal insufficiency (Addison's disease) refers to glucocorticoid deficiency resulting from adrenal gland disease. Central adrenal insufficiency is because of disorders of the pituitary gland (secondary) or the hypothalamus (tertiary). Long-term hypothalamic-pituitary-adrenal (HPA) axis suppression is commonly seen after chronic glucocorticoid therapy (iatrogenic). Transient HPA axis suppression is increasingly being reported in hospitalised patients with acute illness (relative adrenal insufficiency). This article extensively reviews various aetiologies and management of adrenal insufficiency.

Comparison of steroid pulse therapy and conventional oral steroid therapy as initial treatment for autoimmune pancreatitis

BACKGROUND

The efficacy of oral steroid therapy for autoimmune pancreatitis (AIP) is well known, and oral prednisolone treatment is most usually commenced at 30-40 mg/day, but there have been few reports about comparative studies of oral steroid therapy and steroid pulse therapy as the initial treatment for AIP. We studied the clinical course and image findings to estimate the utility of steroid pulse therapy for AIP, comparing it with oral steroid therapy.

METHODS

Laboratory and image findings were assessed retrospectively in 11 patients who received steroid pulse therapy, and the findings were compared to those in 10 patients who received conventional oral steroid therapy.

RESULTS

Change in pancreatic size showed no significant difference between the therapies after 2 weeks of treatment. Significant improvement of lower bile duct strictures after 2 weeks of treatment and that of immunoglobulin values within 6 months were shown with both therapies. However, steroid pulse therapy showed significant improvement of γ-guanosine triphosphate (GTP) in 2 weeks and of alanine aminotransferase (ALT) in 2 and 8 weeks, compared with oral steroid therapy. Moreover, there was one patient in whom the lower bile duct stricture was not improved by oral steroid therapy, but it did show improvement with steroid pulse therapy.

CONCLUSIONS

Initial steroid pulse therapy is a beneficial alternative to oral steroid therapy for the improvement of bile duct lesions. In future, the accumulation of a larger number of patients receiving steroid pulse therapy is needed, and prospective studies will be required.

How to manage perioperative endocrine insufficiency

Patients with endocrinopathies frequently present to the operating room. Although many of these disorders are managed on a chronic basis, patients may have acute changes in the perioperative period that, if left unrecognized, can have a negative effect on perioperative morbidity and mortality. It is imperative that anesthesiologists understand the implications of the surgical stress response on hormonal flux. This article focuses on the 4 most commonly encountered endocrinopathies: diabetes mellitus, hyperthyroidism, hypothyroidism, and adrenal insufficiency. Specific challenges pertaining to patients with pheochromocytoma are also discussed.

Adrenal cortisol secretion capacity in children and adolescents with new-onset, mild Crohn's disease

OBJECTIVES

To evaluate the integrity of the hypothalamic-pituitary-adrenal axis in active Crohn's disease (CD) among children and adolescents.

STUDY DESIGN

We retrieved data on patients with CD who participated in a prospective study where budesonide treatment was evaluated. Basal and adrenocorticotropic hormone and corticotropin-stimulated cortisol levels in 52 children and adolescents with CD were compared with levels obtained in 52 age-matched control subjects. Correlations of cortisol levels with pediatric CD activity index and C-reactive protein (CRP) as an inflammatory marker were also assessed.

RESULTS

Both basal and stimulated cortisol levels in CD were significantly higher than in control subjects: 364 +/- 173 versus 290 +/- 122 nmol/L (P = .029) and 865 +/- 236 versus 738 +/- 148 nmol/L (P < or = .001), respectively. Cortisol levels were correlated with CRP but not with pediatric CD activity index. Unlike in the control group, stimulated cortisol levels in patients with CD were not correlated with basal levels but rather with CRP (positive correlation) and age at diagnosis (negative correlation).

CONCLUSIONS

Contrary to previous reports suggesting that dysregulation of the hypothalamic-pituitary-adrenal axis is implicated in the susceptibility to and severity of CD and other chronic inflammatory diseases, we demonstrated an adequate response of this axis in pediatric CD, in proportion to the inflammation severity.

Surgery in the patient with endocrine dysfunction

Patients with preoperative endocrinopathies represent a particular challenge not only to anesthesiologists but also to surgeons and perioperative clinicians. The "endocrine axis" is complex and has multiple feedback loops, some of which are endocrine and paracrine related, and others that are strongly influenced by the surgical stress response. Familiarity with several of the common endocrinopathies facilitates management in the perioperative period. This article focuses on 4 of the most common endocrinopathies: diabetes mellitus, hyperthyroidism, hypothyroidism, and adrenal insufficiency. Perioperative challenges in patients presenting with pheochromocytoma are also discussed.

Surgery in the patient with endocrine dysfunction

Patients with preoperative endocrinopathies represent a particular challenge not only to anesthesiologists but also to surgeons and perioperative clinicians. The "endocrine axis" is complex and has multiple feedback loops, some of which are endocrine and paracrine related, and others that are strongly influenced by the surgical stress response. Familiarity with several of the common endocrinopathies facilitates management in the perioperative period. This article focuses on 4 of the most common endocrinopathies: diabetes mellitus, hyperthyroidism, hypothyroidism, and adrenal insufficiency. Perioperative challenges in patients presenting with pheochromocytoma are also discussed.

Effect of immunosuppression on patients undergoing bariatric surgery

BACKGROUND

Immunocompromised patients are at high risk of medical complications. Immunosuppression might be a relative contraindication to bariatric surgery. We describe our experience with immunosuppressed patients undergoing bariatric surgery and review the safety, efficacy, results, and outcomes.

METHODS

We performed a retrospective review of prospectively collected data. All patients taking long-term immunosuppressive medications or with a diagnosis of an immunosuppressive condition were included in this study. Data on weight loss, co-morbidities, complications, and postoperative immunosuppression were collected.

RESULTS

From July 1999 to February 2008, 1566 patients underwent bariatric surgery. Of these 1566 patients, 61 (3.9%) were taking immunosuppressive medications or had an immunosuppressive condition. Of these 61 patients, 49 were taking immunosuppressive medications for asthma, autoimmune disorders, endocrine deficiency, or chronic inflammatory disorders. The medications included oral, inhaled, and topical glucocorticoids for 39 patients and other immunosuppressive or disease-modifying antirheumatic drugs for 24 patients. The bariatric procedures included laparoscopic Roux-en-Y gastric bypass in 55, laparoscopic revisional procedures in 5, and laparoscopic sleeve gastrectomy in 1. No patient died perioperatively. A total of 26 complications occurred in 20 patients. The average percentage of excess weight loss was 72% (range 20-109%) at 1 year postoperatively. At a median postoperative follow-up of 18 months (range 2-68.6), 25 (51%) of 49 patients no longer required immunosuppressive medications owing to improvement of their underlying disease. Obesity-related health problems (diabetes mellitus, hypertension, obstructive sleep apnea, gastroesophageal reflux disease, asthma) had resolved or improved in 80-100% of patients.

CONCLUSION

The results of our study have shown that immunocompromised patients can safely undergo bariatric surgery with good weight loss results and improvement in co-morbidities. A large percentage of patients were able to discontinue immunosuppressive medications postoperatively.

Corticosteroid-induced adverse events in adults: frequency, screening and prevention

Corticosteroids represent the most important and frequently used class of anti-inflammatory drugs and are the reference therapy for numerous neoplastic, immunological and allergic diseases. However, their substantial efficacy is often counter-balanced by multiple adverse events. These corticosteroid-induced adverse events represent a broad clinical and biological spectrum from mild irritability to severe and life-threatening adrenal insufficiency or cardiovascular events. The purpose of this article is to provide an overview of the available data regarding the frequency, screening and prevention of the adverse events observed in adults during systemic corticosteroid therapy (topically administered corticosteroids are outside the remit of this review). These include clinical (i.e. adipose tissue redistribution, hypertension, cardiovascular risk, osteoporosis, myopathy, peptic ulcer, adrenal insufficiency, infections, mood disorders, ophthalmological disorders, skin disorders, menstrual disorders, aseptic necrosis, pancreatitis) and biological (i.e. electrolytes homeostasis, diabetogenesis, dyslipidaemia) events. Lastly, data about the prescription of corticosteroids during pregnancy are provided. This review underscores the absence of data on many of these adverse events (e.g. lipodystrophy, dyslipidaemia). Our intent is to present to practitioners data that can be used in a practical way to both screen and prevent most of the adverse events observed during systemic corticosteroid therapy.

Que reste-t-il de l'insuffisance surrénale post-corticothérapie?

Adrenal insufficiency (AI) induced by glucocorticoids was first described more than 50 years ago in patients undergoing surgical stress. Although considered the most frequent cause of AI, the true incidence of this complication of glucocorticoid treatment remains unknown. No factors are known to predict AI after glucocorticoid treatment. In particular, neither the dose nor the duration of treatment seems predictive. The minimum dose of cortisol necessary for the body to cope with medical or surgical stress is unknown. The adrenocorticotropin test is often used during corticosteroid withdrawal because it is well correlated with adrenal response to surgical stress, but not with clinical events. Studies over the past 15 years have shown that the perioperative risk of AI has been overestimated and that hydrocortisone doses should be decreased. A prospective study of patients after steroid withdrawal is the only means of assessing the true incidence of this complication to propose a rational strategy to prevent it.

Perioperative management of immunosuppression

Current immunosuppressive regimens typically consist of two phases: induction phase (medications given at the time of the initial transplant) and maintenance therapy. Induction medications are given to decrease the occurrence of early acute rejection, avoid or minimise corticosteroids, and potentially induce long-term favourable immunoregulatory effects. As tolerance remains an elusive goal, life-long maintenance immunosuppression is required after all solid-organ transplantations. The various agents used in these two phases of immunosuppression are reviewed in this article. The similarities and differences between the agents within each class, with respect to efficacy and tolerability, are discussed.

Adrenal insufficiency: diagnosis and management

Adrenal insufficiency is a disorder characterized by hypoactive adrenal glands resulting in insufficient production of the hormones cortisol and aldosterone by the adrenal cortex. This disorder may develop as a primary failure of the adrenal cortex or be secondary to an abnormality of the hypothalamic-pituitary axis. Patients with adrenal insufficiency often are asymptomatic or they may present with fatigue, muscle weakness, weight loss, low blood pressure, and sometimes darkening of the skin. The presentation of adrenal insufficiency varies dramatically and poses a major diagnostic dilemma. This review focuses on the diagnosis and treatment of primary and secondary adrenal insufficiency.

[Adrenal cortex and steroids. Supplementary therapy in the perioperative phase]

Since the publication of two case reports that are considered to represent the first clinical demonstration of iatrogenic adrenal insufficiency, it has been the generally accepted practice to cover steroid-treated patients undergoing surgery with glucocorticoids in the perioperative period. Both the inclusion criteria for the patients and the extent of the substitution pattern have been selected on an empirical rather than on a rational basis. Scientific advances over the past 50 years in the knowledge of the hypothalamic-pituitary-adrenal system's physiology and the molecular mechanism of action of its biologically active components are, for the most part, not reflected in current clinical practice and instead seem to be ignored. Clinical and experimental evidence suggests, however, that even glucocorticoid-treated patients undergoing surgery do not require maximum stress doses of hydrocortisone, which should be reserved for the treatment of sepsis. With regard to the broad spectrum of efficacy of glucocorticoids and their side effects, revision and modification of the historical regimen appear prudent.

Methods to avoid infections in patients with inflammatory bowel disease

Infections have been reported in patients with inflammatory bowel disease (IBD), especially in association with anti-inflammatory and immunomodulatory medications used to treat IBD. Unfortunately, there is a dearth of information on infectious complication risk in patients with IBD. This review describes infectious complications reported in patients with IBD and provides a framework for future studies to assess potential risk factors and incidence for infection. Recommendations are also provided for prevention of infection.