Safety of withholding perioperative steroids for patients with pituitary resection with an intact hypothalamus-pituitary-adrenal axis: A meta-analysis of randomized clinical trials

Introduction: Several observational studies have evaluated the effects of pre-operative steroids (STER) for transsphenoidal pituitary removal in patients with an intact hypothalamus-pituitary-adrenal axis. However, a consensus built upon randomized studies has not been previously performed. Purpose: To comprehensively evaluate the clinical effects of patients receiving STER when compared to those not receiving steroids (NOSTER) in transsphenoidal pituitary resection, a meta-analysis of randomized clinical trials (RCT) was conducted. Methods: A systematic review of the literature of RCTs comparing STER and NOSTER was performed in accordance with the PRISMA guidelines. Databases, including PUBMED, Cochrane Library, Web of Science, and Embase were queried. The primary outcomes were adrenal insufficiency (AI) and diabetes insipidus (DI) postoperatively. Results: A total of 4 final studies were included, in which 530 total patients were analyzed. The meta-analysis suggested that there was no significant difference between STER and NOSTER groups post-operatively related to transient AI (RR= 0.83, 95% CI [0.51-1.35], p = 0.45; I-2 = 52%), permanent AI (RR= 0.97, 95% CI [0.41-2.31], p = 0.95; I-2 = 0%), and permanent DI (RR= 0.62, 95% CI [0.16-2.33], p = 0.48; I-2 = 0%). Nevertheless, STER group had significantly lower rates of transient DI (RR= 0.60, 95% CI [0.38-0.95], p = 0.03; I-2 = 5%), and post-op hyponatremia (RR = 0.49, 95% CI [0.28-0.87], p = 0.02; I-2 = 0%). Conclusion: This study demonstrates evidence from RCTs that patients receiving pre-operative STER are both safe and effective pre-operatively for resection of pituitary adenomas with an intact hypothalamus-pituitary-adrenal axis.