A patient on long-term high-dose prednisolone is scheduled for surgery. She has been on 10 mg/day for 9 months. The reason for perioperative steroid supplementation is:

• A Chronic supraphysiological glucocorticoid suppresses hypothalamic-pituitary-adrenal axis, impairing stress cortisol surge ✓
• B Prednisolone inhibits hepatic glucose-6-phosphatase, requiring exogenous glucose support
• C Prednisolone depletes adrenal catecholamine stores, preventing surgical stress response
• D Surgery accelerates prednisolone metabolism by upregulating CYP3A4

Explanation

Chronic exogenous glucocorticoid administration causes feedback suppression of CRH (hypothalamus) and ACTH (pituitary), resulting in adrenal cortex atrophy. Under surgical stress, the normal cortisol surge (up to 200–500 mg/day) cannot occur; without supplementation, the patient risks addisonian crisis with hypotension, hyponatraemia and circulatory collapse. Patients on ≥5 mg prednisolone for >3 weeks need perioperative hydrocortisone cover.

Reference: KD Tripathi, Essentials of Medical Pharmacology, 8th ed.

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Written and medically reviewed by the StethoPrep medical team.