Perioperative Management of Oral Budesonide
Oral budesonide used chronically should generally be continued through the day of surgery and should not be stopped preoperatively. [1][2] If adrenal suppression is a concern based on the patient’s glucocorticoid history, perioperative supplemental glucocorticoids should be provided rather than stopping budesonide. [2][3]
Medication Selection Algorithm
Chronic oral budesonide should be managed as systemic glucocorticoid therapy for perioperative purposes. [1][2] Perioperative glucocorticoid handling should follow 2 parallel steps. [2]
- Baseline regimen should be continued until surgery day (including the day of surgery). [1]
- Adrenal insufficiency risk should be assessed to determine whether perioperative supplemental glucocorticoids are required. [2][3]
Key Evidence Supporting This Recommendation
Consensus guidance for perioperative chronic glucocorticoids states that glucocorticoids should be continued until the day of surgery inclusively. [1] Guidance for patients with adrenal insufficiency emphasizes perioperative glucocorticoid supplementation to prevent adrenal crisis during physiologic surgical stress. [3]
Monotherapy Versus Combination Therapy
When adrenal suppression risk is present, perioperative glucocorticoid coverage is provided by continuing the usual baseline regimen and adding supplemental glucocorticoid dosing for the perioperative period. [2][3] Stopping chronic glucocorticoids preoperatively is not recommended as a strategy for preventing adrenal crisis. [2][3]
Important Clarifications and Nuances
Dose-dependent adrenal suppression risk may require supplemental perioperative dosing even when baseline glucocorticoids are continued. [2][3] Perioperative management should include informing the anesthesia team of the equivalent prednisolone dose and the timing of the last dose. [1]
Initiation Thresholds or Indications
Perioperative supplementation decisions should be based on adrenal insufficiency risk assessment and surgical stress rather than on a routine “stop date” for chronic budesonide. [2][3] Patients with higher risk features may require supplemental hydrocortisone dosing with specific perioperative schedules depending on surgical stress and clinical status. [3]
Common Pitfalls to Avoid
Stopping chronic systemic glucocorticoids before surgery can create risk for perioperative adrenal insufficiency. [2][3] Failing to communicate systemic glucocorticoid exposure (including recent use) to anesthesia can lead to inadequate perioperative glucocorticoid coverage. [1]
Targets or Goals of Therapy
The goal of perioperative glucocorticoid management is maintenance of adequate glucocorticoid effect to prevent adrenal crisis during surgery while avoiding unnecessary discontinuation of baseline therapy. [2][3]
Practical Answer: When Oral Budesonide Should Be Stopped Before Surgery
Oral budesonide should not be stopped shortly before surgery in patients receiving it chronically. [1][2] If supplemental perioperative glucocorticoids are required due to adrenal suppression risk, they should be added to perioperative management while budesonide is continued through surgery day. [1][3]