Thursday, January 5, 2017

Glucocorticoid Tapering Regimen


Rationale
  • possible cortisol deficiency resulting from hypothalamic-pituitary-adrenal axis (HPA) suppression during the period of steroid therapy
Indication for Immediate Cessation
  • Immediate cessation or reduction to physiological doses (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
HPA suppression
Criteria
Action
likely
  • more than 20 mg of prednisone a day for more than three weeks
  • evening/bedtime dose of ≥5 mg of prednisone for more than a few weeks
  • patient who has a Cushingoid appearance
  • do not need testing to evaluate their HPA function
  • be treated like any patient with secondary adrenal insufficiency
unlikely
  • any dose of glucocorticoid for less than three weeks
  • alternate-day prednisone at a dose of less than 10 mg (or its equivalent)
  • gradual reduction in dose
  • do not need to be tested for HPA functional reserve
Intermediate/ uncertain
  • 10 to 20 mg of prednisone per day for more than three weeks
  • less than 10 mg of prednisone (providing that it is not taken as a single bedtime dose) for more than a few weeks

Tapering regimen
Short-term glucocorticoid therapy
(up to three weeks), even if at a fairly high dose
  • stopped and need not be tapered
  • (HPA) suppression due to glucocorticoid use of this duration will not persist and is highly unlikely to have any clinical consequence.
  • proceed more cautiously in a frail or dangerously ill patient
glucocorticoid for a longer time
  • suggest a regimen which is largely based factors of age, frailty, concomitant illnesses, dangerousness and likelihood of flare of underlying illness, psychological factors, and duration of previous use of glucocorticoids are taken into account
  • aim for a relatively stable decrement of 10 to 20 percent, while accommodating convenience

Example
Current Dose (mg/day)
Reduce by (mg/day)
Duration
> 40
5-10
every 1-2 weeks
20-40
5
every 1-2 weeks
10-20
2.5
every 2-3 weeks
5-10
1
every 2-4 weeks
<5
0.5
every 2-4 weeks
symptoms of cortisol deficiency
  • many patients with rheumatic diseases complain of recurrent symptoms of the underlying disease
Alternate day regimen

generally effective in most rheumatic diseases, patients with rheumatoid arthritis often do not tolerate alternate-day dosing    
not major
Use NSAIDS or analgesia
wait 7 to 10 days
If the symptoms do not subside
increase the prednisone dose by 10 to 15%
Maintain for 2-4 weeks
increase in dose not sufficient
double the prednisone dose
Disease flare is allowed to subside Taper is reinstituted at a slower rate or at smaller decrements
life-threatening flares
(acute recurrence of lupus nephritis, severe hemolysis, acute polymyositis, or vasculitis)
original, highest dose of steroids should be instituted
Flare is allowed to subside
Taper is reinstituted at a slower rate or at smaller decrements
If the symptoms resolve
above tapering regimen can be resumed
Every 2-4 weeks rather than 1-2 weeks

Reference:
www.uptodate.com

No comments:

Post a Comment

Note: Only a member of this blog may post a comment.