We thank Dr. Wax for his response to our recent article on perioperative steroid management.1  Since the publication of our article, we have received several queries regarding the use of dexamethasone as a perioperative stress-dose steroid and appreciate the opportunity to further address this topic. As Dr. Wax aptly notes, dexamethasone has significantly more glucocorticoid potency than hydrocortisone, has no mineralocorticoid effect, and can be clinically effective in the prevention of postoperative nausea and vomiting. Indeed, the recommended antiemetic dose of dexamethasone (4 mg) has at least the same glucocorticoid equivalence as the recommended intraoperative stress dose of hydrocortisone (100 mg) for patients at risk for adrenal insufficiency undergoing major surgery.1  The available literature on perioperative steroid supplementation provides dosing guidelines based on hydrocortisone, which has a shorter, more predictable half life compared to dexamethasone and is thus more easily tapered to the usual daily dose in patients requiring continued postoperative supplementation based on surgical stress. However, the literature on patients with secondary adrenal insufficiency does not make any specific recommendation as to what is the “best” stress-dose steroid to administer. Dexamethasone is not appropriate for patients with primary adrenal insufficiency or critically ill patients, both of whom require mineralocorticoid supplementation.2,3  While we agree that the use of dexamethasone may be a reasonable approach for many patients with secondary adrenal insufficiency, with additional benefit in the prevention of postoperative nausea and vomiting, we caution against a “one-size-fits-all algorithm,” especially in critically ill patients.

The authors declare no competing interests.

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Liu
MM
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Reidy
AB
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Saatee
S
,
Collard
CD
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Perioperative steroid management: Approaches based on current evidence.
Anesthesiology
2017
;
127
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72
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Bornstein
SR
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Allolio
B
,
Arlt
W
,
Barthel
A
,
Don-Wauchope
A
,
Hammer
GD
,
Husebye
ES
,
Merke
DP
,
Murad
MH
,
Stratakis
CA
,
Torpy
DJ
:
Diagnosis and treatment of primary adrenal insufficiency: An endocrine society clinical practice guideline.
J Clin Endocrinol Metab
2016
;
101
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364
89
3.
Cooper
MS
,
Stewart
PM
:
Corticosteroid insufficiency in acutely ill patients.
N Engl J Med
2003
;
348
:
727
34