Steroid withdrawal or tapering

Indication of steroid therapy

• Endocrine: replacement therapy, Graves ophthalmopathy
• SKIN: Dermatitis, Pemphigus
• Hematologic: Leukemia, lymphoma, hemolytic anaemia, ITP
• GIT: IBD
• Hepatic: CAH, transplantation, organ rejection
• CNS: Cerebral edema, raised ICP, Myasthenia Gravis
• Renal: Nephrotic syndrome, Vasculitidis, transplantation
• Respiratory: Asthma, COPD, TB, Angioedema, Sarcoidosis, Anaphylaxis
• Rheumatologic: SLE, RA, PAN, polymyalgia Rheumatica

Initiation of steroid therapy

• Severity of the disorder
• Presumed duration of therapy
• Exacerbation of pre-existing condition
• Steroid preparation:

• biologic half life
• mineralocorticoid effect
• biologically active form
• cost of medication
• type of formulation

Equivalent dose of steroid (D-PHC: 0.5-5-20-25)

• Prednisolone- 5mg
• Dexamethasone-0.5 mg
• Hydrocortisone- 20 mg
• Cortisone acetate-25 mg

A Checklist for Use Prior to the Administration of Glucocorticoids in Pharmacologic Doses

• Presence of tuberculosis or other chronic infection (chest x-ray, tuberculin test)
• Evidence of glucose intolerance or history of gestational diabetes mellitus
• Evidence of preexisting osteoporosis (bone density assessment in organ transplant recipients or postmenopausal patients)
• History of peptic ulcer, gastritis, or esophagitis (stool guaiac test) 
• Evidence of hypertension or cardiovascular disease
• History of psychological disorders

Supplementary Measures to Minimize Undesirable Metabolic Effects of Glucocorticoids

• Monitor caloric intake to prevent weight gain
• Restrict sodium intake to prevent edema and minimize hypertension and potassium loss. 
• Provide supplementary potassium if necessary. 
• Provide antacid, PPI
• Institute alternate-day steroid schedule if possible. 
• Patients receiving steroid therapy over a prolonged period should be protected by an appropriate increase in hormone level during periods of acute stress. A rule of thumb is to “double the maintenance dose”.
• Minimize osteopenia by

• Administering gonadal hormone replacement therapy: 0.625-1.25 mg conjugated estrogens given cyclically with progesterone, unless the uterus is absent; testosterone replacement for hypogonadal men
• Ensuring high calcium intake (should be approximately 1200 mg/d) 
• Administering supplemental vitamin D if blood levels are reduced.
• Administering bisphosphonate prophylactically, orally or parenterally, in high-risk patients

HPA axis suppression

• Repeated short course therapy in preceding year
• Evening dose of steroid
• Suppression invariable if prednisolone dose>15 mg/day, variable if between 5- 15 mg/day for long duration
• Unlikely if any dose used for < 3 weeks

When to suspect HPA suppression

• Chronic steroid therapy in supraphysiologic dose
• Feature of iatrogenic Cushing syndrome:

• Metabolic feature more common: HTN, DM or IGT, osteoporosis, AVN of neck of femur

• Ocular feature more common
• Acute pancreatitis
• Uncommon feature: Hirsutism, oligo/amenorrhoea
• In absence of replacement therapy symptoms of steroid deficiency: 

• anorexia, nausea, vomiting, body ache, abdminal Pain, desquamation, crisis if abrupt withdrawal

• Plasma cortisol, 24-hr-UFC low with suppressed ACTH

Steroid withdrawal protocol

• • The suppressed axis may take 6-9 months to recover
  • At first recovery of CRH, then ACTH, finally cortisol
  • After remission of primary disease, continue current dose for 4-6 weeks
  • If dose > 40 mg/day:
    • taper by 10 mg at 2 week interval

• When between 20-40 mg/day 

• • • taper by 5 mg at 2 week interval
  • When between 7.5 – 20 mg/day 
    • taper by 2.5 mg  at 2 week interval to 7.5mg/day

• Then 1mg  every 2-4 days up to 5mg/day

• Then go to alternate day regime if desired, OR, 
  • change to hydrocortisone 20 mg/day and taper to 10 mg/day  by 2.5mg/week
• Continue physiologic replacement dose for 2-3 months. 
• Then do basal cortisol level at 9.00 AM before the next dose.

        < 3µgm/dl                                    3-20µgm/dl                              >20µgm/dl

     Continue as before                       SST                                Recovered HPA Axis, 

                                                                                                           so discontinue therapy

basal cortisol after 3 months                 S. cortisol > 550 → withdraw

1. Cortisol < 550 → ? 

[Hydrocortisone is short acting so serum basal cortisol can be measured without error in result; same to alternative day therapy (after one day off serum cortisol is measured.]

Synacthen test

• Short Synacthen test
• long Synacthen test
• Low dose SST