**Question:** A 30 year old female who is known case of lupus is posted for myomectomy. She has been taking 20 mg prednisolone since she was 19. What is your advice regarding perioperative steroid replacement?

**Core Concept:** Prednisolone is a corticosteroid used to suppress the immune system in patients with autoimmune diseases like lupus. In this scenario, the patient has been on prednisolone for a long duration and will require guidance on perioperative steroid replacement.

**Why the Correct Answer is Right:** Prednisolone is a potent immunosuppressive drug, and abrupt discontinuation can lead to a flare of her underlying lupus symptoms. Therefore, perioperative steroid replacement is essential to avoid such complications.

**Why Each Wrong Option is Incorrect:**

A. Decrease in dose: This is incorrect as abrupt discontinuation can lead to a flare of her lupus symptoms.
B. Gradual tapering: This is partially correct but does not address the need for replacement therapy during surgery, which is crucial to prevent lupus flare.
C. No steroid replacement: This is incorrect as it fails to address the need for perioperative immunosuppression to prevent lupus flare.
D. No steroid replacement: Similar to option C, this option also neglects the importance of perioperative immunosuppression.

**Clinical Pearl:** In patients with autoimmune diseases like lupus receiving long-term corticosteroids, a well-planned perioperative steroid replacement strategy is crucial to prevent lupus flare and ensure a safe surgical procedure. This includes assessing the patient's preoperative cortisol levels and creating a steroid replacement plan based on her individual requirements.

**Correct Answer:** Option D: No steroid replacement.

In this scenario, discontinuing prednisolone abruptly can lead to a lupus flare, which may pose a significant risk to the patient during surgery. Therefore, it is essential to maintain her cortisol levels and avoid abrupt discontinuation of prednisolone. Instead, a gradual tapering process should be planned, and the replacement therapy should be initiated during surgery and continued postoperatively based on her individual requirements.