Steroid precautions for hypoadrenal patients undergoing surgery or other procedures

Patients with hypoadrenalism of any cause require special precautions before undergoing invasive procedures. This advice applies to patients with Addison's disease, hypopituitarism, or long term adrenal suppression and covers procedures such as endoscopy, dental work and major surgery.

Is the patient known to have Addison's disease? 

The majority of patients presenting with Addisonian crisis will have long standing Addison's disease or other cause of hypoadrenalism, though some new patients will present with a crisis. 

Is the patient known to have a pituitary or adrenal problem? 

Patients known to have pituitary disease are obviously at high risk of this presentation.

Patients who have undergone bilateral adrenalectomy should obviously be taking glucocorticoid replacement therapy. However, patients who have undergone unilateral adrenalectomy are also at risk, in particular if the surgery was for Cushing's, though Conn's syndrome adenomas may also co-secrete cortisol and so be associated with ACTH deficiency post op, and adrenal incidentalomas may also cause subclinical Cushing's. 

Patients with a history of adrenal infarction, tuberculocis or with metastatic disease are all also at risk of becoming Addisonian.

Does the patient usually take any form of steroid therapy? 

Patients on long term glucocorticoid therapy for any reason are at risk of Addisonian crises. For example, patients on long term prednisolone (typically over 7mg a day for more than 3 months), for polymyalgia rheumatica, inflammatory bowel disease or asthma may present acutely unwell if their need for increased dose steroids during intercurrent illness has not been recognised.

Does the patient carry any emergency medical identification or a steroid card? 

Patients on long term steroids should generally carry a steroid warning card.

Patients with known glucocorticoid deficiency should also wear emergency medical identification.

What is the nature of the procedure to be undertaken, and is this an emergency or elective / planned procedure? 

The level of precautions required varies commensurate with the scale of the procedure e.g. minor dental work requires little preparation, though a colonoscopy can require detailed pre planning.