Treatment with more than 5 mg of prednisone (or its steroid equivalent) for more than 3 weeks may cause adrenal cortical atrophy as a result of chronic suppression of ACTH production.  Complete recovery of the hypothalamic-pituitary-adrenal (HPA) axis may take up to 12 months after glucocorticoid treatment has been discontinued [1-6].  During this recovery time the ability to increase cortisol production is limited, and stressful situations that increase the demand for cortisol may trigger adrenal insufficiency. Supplementation of the glucocorticoid dosage  during stressful situations (stress dose) such as surgery and critical illness has been advised to prevent vascular collapse due to secondary adrenal insufficiency. The stress doses recommended depend on the intensity and duration of the stress[4, 5]. However, there is some evidence to suggest that "stress dose" steroids may be unnecessary, and that continuing steroid-dependent patients on their preoperative dose throughout the perioperative period should suffice to prevent a hypotensive crisis [7-10].

Nonetheless, the above studies may not apply to the pregnant state. It has been recommended by one author that patients with known Addison disease during pregnancy receive 100 mg of hydrocortisone every 6 to 8 hours during labor, and this is continued post partum for 24 hours. After 24 hours the patient may return to her  prepregnancy regimen [15]. For women without Addison disease delivery appears to result in a similar rise in cortisol levels amongst women whether delivered vaginally or by cesarean section. However, initial cortisol values may be higher in women undergoing induction of labor and elective cesarean [11,12]. The timing of these increases in cortisol should be considered if "stress dose" steroids are to be prescribed.

Recommended Perioperative Hydrocortisone Glucocorticoid for Patients on Long Term Steroid Treatment [4,5].

IN ADDITION TO to the patient's usual dose of steroid preoperatively give the following:

Other steroids may be substituted for hydrocortisone using the steroid equivalent dose; For example 1 mg methylprednisolone may be substituted for each  5 mg hydrocortisone.

For women whose medication history is uncertain an ACTH (adrenocorticotropic hormone) stimulation test may be done. The test is performed by obtaining a baseline serum cortisol, and then giving ACTH 250 mcg IV. The serum cortisol is drawn at 30 minutes and 60 minutes after the ACTH dose. Peak cortisol values greater than 18 micrograms/100 mL at any point during the ACTH stimulation indicate adequate adrenal-pituitary-hypothalamic function in the nonpregnant patient. An increase in cortisol above 2 to 3 times the baseline also indicates adequate adrenal function.