‫‪Glucocorticoid‬‬

‫‪withdrawal‬‬

‫المركز التخصصي للأمراض‬

‫التنفسية في ذي قار‬
introduction

▪ Chronic glucocorticoid therapy is used in the treatment of a

variety of disorders because of its potent antiinflammatory
effects and, occasionally, because it is thought to have
immunosuppressive activity
▪ Despite its efficacy, steroid-induced side effects generally
require tapering of the drug as soon as the disease being
treated is under control. Tapering must be done carefully to
avoid both recurrent activity of the underlying disease and
possible cortisol deficiency resulting from hypothalamic-
pituitary-adrenal axis (HPA) suppression during the period
of steroid therapy
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▪ there are two complications that require immediate cessation

of glucocorticoids or a significant rapid reduction, rather than
tapering:
▪ ●Steroid-induced acute psychosis that is unresponsive to
antipsychotic medications
▪ ●Herpesvirus-induced corneal ulceration, which can rapidly lead
to perforation of the cornea and possibly permanent blindness
▪ If immediate cessation is not possible (eg, because of a critical
clinical need), use of the lowest necessary dose, then
discontinuing steroids as soon as possible, is strongly advised.
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 Hypothalamic pituitary adrenal axes

▪ HPA suppression may occur regardless of whether glucocorticoids

are administered in the morning or evening.
▪ HPA suppression depend on dose, duration and concomitant drugs
like azoles that enhance glucocorticoids action.
▪ HPA suppression unlikely — Patients who meet one of the
following criteria regarding glucocorticoid use are less likely to
have a suppressed HPA and therefore may have glucocorticoids
weaned as is appropriate for the underlying disease:
▪ ●A patient who has received glucocorticoids for less than three
weeks
▪ ●Patients treated with alternate-day prednisone at a dose of
less than 10 mg (or its equivalent)
Estimation of HPA suppression

▪ Identifying the degree of HPA suppression is not simple

clinically. Thus, in practice it is unusual to perform any
testing of HPA function prior to beginning the glucocorticoid
withdrawal process. However, in certain settings (eg, the
patient for whom elective surgery is planned) such testing
(e.g. cosyntropin test) may be warranted.
▪ Testing for HPA-axis function is appropriate when patients
are using <5 mg/day of prednisone and there is difficulty
reducing the dose further because of symptoms related to
adrenal insufficiency.
• Short-term glucocorticoid therapy (up to
three weeks) can usually be stopped
without a taper.

• patients who have taken a glucocorticoid

with highly suspicion of HPA suppression
1.Glucocorticoid taken> 3wks
2. have a Cushingoid appearance
3. received evening dosing
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Other forms of steroid dependence (beyond symptomatic and

biochemical evidence of [HPA] suppression) have been
identified which can hinder steroid tapering. These include :

●Psychologic dependence on steroids

●Recrudescence of the disease for which the drug was
prescribed
●Symptoms of apparent adrenal insufficiency despite normal
HPA function and lack of disease recrudescence
 The dose is tapered by:
●5 to 10 mg/day every 1 to 2 weeks from an initial dose above 40 mg
of prednisone or equivalent per day.
●5 mg/day every 1 to 2 weeks at prednisone doses between 40 and 20
mg/day.
●2.5 mg/day every 2 to 3 weeks at prednisone doses between 20 and
10 mg/day.
●1 mg/day every 2 to 4 weeks at prednisone doses between 10 and 5
mg/day.
●0.5 mg/day every 2 to 4 weeks at prednisone doses from 5 mg/day
down. This can be achieved by alternating daily doses, eg, 5 mg on day
one and 4 mg on day two
 Alternate-day regimen

After the daily regimen has reached 20 to 30 mg of prednisone per

day, we decrease the alternate day dose by 5 mg every one to two
weeks until the dose is 20 to 30 mg alternating with 10 mg.

We then reduce the alternate-day dose by 2.5 mg every one to two

weeks until the prednisone dose on the alternate day has fallen to
zero.

At that point we decrease the remaining drug in the same manner as

was suggested for the daily dosing regimen.
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