Preoperative low-dose steroids sufficient for steroid-treated IBD

Image: PD/Colitis

1. 96% of the low dose and 95% of the high dose patients did not experience postural hypotension on postoperative day (POD) 1.

2. There were no differences in perioperative treatments required between the low and high dose steroid groups (volume of intravenous fluids, blood transfusions, etc.). 

3. There were no significant differences in 30-day post-operative complications.

Evidence Rating Level: 1 (Excellent) 

Study Rundown: This randomized-controlled trial provides strong evidence that low-dose steroids (LDS) and high-dose steroids (HDS) are similar in effectiveness for the prevention of adrenal insufficiency in steroid-treated inflammatory bowel disease (IBD) patients prior to and during surgery.  Its findings suggest that HDS are unnecessary for these patients when they undergo surgery, and may be exposing patients to other unnecessary risks of steroid use.  Strengths of this study include its blinding of patients and randomization of eligible patients.  In measuring perioperative hemodynamic factors as well as 30-day post-operative complications, it considers broadly the effects of both treatments and does not find significant differences in the outcomes.  Limitations of this study include the inability to account for differences in duration of prior steroid therapy for those patients still taking steroids at the time of surgery.  Similarly, for patients no longer taking steroids, the difference in median months before surgery that the steroids were discontinued could affect each group’s likelihood of developing adrenal insufficiency.  Further studies are needed with different analyses for patients still taking steroids at the time of surgery and those that stopped prior to surgery.

Click to read the study in Annals of Surgery

In-Depth [randomized controlled trial]: This single-center, randomized, patient-blinded trial compared LDS vs. HDS in IBD patients normally treated with steroids.  Patients 18-75 years of age treated with corticosteroids in the past year, and undergoing major colorectal surgery were considered.  49 received LDS and 43 received HDS.  HDS patients received 100 mg of hydrocortisone at the time of incision and during the first 24 hours every 8 hours, then began a gradual taper on POD 1.  No additional steroids were given for the prevention of post-operative nausea.  LDS were given one-third the dose to start.  After randomization, patients in the HDS still taking steroids for IBD had a median prednisone dose of 30 mg compared to 20 mg in the LDS group.  Also, duration of previous steroid therapy for patients randomized into the HDS group was 20 months, as compared to only 9 months for the LDS group. No measurable perioperative differences were observed in the volume of intravenous fluids given, blood transfusions, or fluid boluses required.  There was no difference in postural hypotension on POD1 between the two groups (95% and 96%).  There were also no significant differences in any of the other hemodynamic parameters measured.  30-day post-operative complications were also similar between both groups.

By David Mattos and Allen Ho

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