Contraindications to Perioperative Corticosteroid Use

There are no studies in the literature that directly address contraindications to perioperative corticosteroid use in primary TJA. There is a concern that corticosteroids should be used with caution in patients with diabetes mellitus as this may lead to an increase in postoperative blood glucose levels. The long-term medical consequences of uncontrolled diabetes are well understood, but the short-term effects of transient increases in blood glucose remain unknown in both diabetic and non-diabetic patients. With regards to complications specific to TJA, Kheir et al. found that postoperative blood glucose levels on postoperative day 1 predict the risk of periprosthetic joint infection with a linear increase in the risk of PJI for blood glucose levels beyond 115 mg/dL.[18] The authors report that the optimal blood glucose threshold to reduce the risk of PJI is 137 mg/dL.

Of the 16 studies included in this clinical practice guideline evaluating dexamethasone, four studies excluded all patients with diabetes mellitus regardless of the type of diabetes or their hemoglobin A1c (HbA1c).[2–4,17] Three studies excluded patients with poorly controlled diabetes, defined as a HbA1c > 7.5%.[9,10,14] One additional study excluded all type I diabetics as well as patients with a HbA1c > 7%.[13] Given patients with diabetes mellitus were excluded from a majority of the included studies in this clinical practice guideline, there is not enough evidence to make an evidence-based recommendation on the use of corticosteroids in patients with diabetes mellitus. However, it is the opinion of the workgroup that corticosteroids should be used with caution in patients with both type I and type II diabetes mellitus due to the aforementioned risks of both medical and TJA specific complications including PJI and wound complications. The authors recommend providers consider postoperative blood glucose monitoring in patients with diabetes mellitus that receive intravenous dexamethasone. The timing, dose, number of doses, and frequency of doses should be individualized to each patient based on their type of diabetes and their HbA1c.