Re: INFO - Why stopping prednisone must usually be done gradually

September 20, 2004

Thanks for the info.

Beth

--- In , " " <Matsumura_Clan@m...>

wrote:

> An excerpt from:

>

> Merck

> Best Practice of Medicine

> " Glucocorticoid Therapy and Withdrawal " :

>

> Glucocorticoid Withdrawal

>

> Glucocorticoid withdrawal can present with symptoms of chronic

> glucocorticoid deficiency or as an acute adrenal crisis [22]. Thus,

> patients may suffer from anorexia, myalgia, nausea, emesis, lethargy,

> headache, fever, skin desquamation, arthralgias, weight loss, and

> postural hypotension. In addition, they may experience exacerbation of

> previously present autoimmune disease (eg, rheumatoid arthritis, atopic

> dermatitis, or asthma) or have new autoimmune disease (eg, Hashimoto's

> thyroiditis or Graves disease). The occurrence of the subjective

> component of the steroid withdrawal syndrome does not depend on the

> absence of cortisol from the circulation or an impairment of the

> hypothalamic-pituitary-adrenal axis, because many of these symptoms may

> occur while on proper glucocorticoid replacement or while the patient

> has a normal cortisol response to Cortrosyn (Organon, Inc.). In this

> instance, the steroid withdrawal syndrome may be a result of

> difficulties in withdrawing from the high levels of glucocorticoids - a

> phenomenon that appears to be idiosyncratic [24].

>

> Termination of chronic daily glucocorticoid therapy (longer than 2

> weeks) should be gradual - both to prevent development of adrenal

> insufficiency and to avoid reactivation of the disease under therapy

> (Table 6). The likelihood of the latter depends on the activity and

> natural history of the disorder. When there is any chance that the

> underlying illness may recur, the glucocorticoids should be withdrawn

> slowly over a period of weeks to months with frequent reassessment of

> the patients condition. Daily hydrocortisone replacement or double or

> triple replacement of intermediate-acting glucocorticoids given on

> alternate days are acceptable methods for weaning patients from

> glucocorticoid therapy.

>

> Adrenal Suppression

>

> Recovery of the hypothalamic-pituitary-adrenal axis can take 12

> months or longer [9]. Abrupt cessation of glucocorticoid treatment or

> quick tapering can precipitate an acute adrenal insufficiency crisis.

> The main symptoms range from anorexia, fatigue, nausea, vomiting,

> dyspnea, fever, arthralgia, myalgia, and orthostatic hypotension to

> dizziness, fainting, and circulatory collapse. Hypoglycemia is

> occasionally observed in children and very thin adult individuals. The

> diagnosis is a medical emergency, and treatment should be immediate

> administration of fluids, electrolytes, glucose, and parenteral

> glucocorticoids.

>

> To evaluate adequacy of hypothalamic-pituitary-adrenal axis

> recovery the rapid Cortrosyn (Organon, Inc.) test should be used. An

> intravenous bolus of 250 g of corticotropin 124 (Cortrosyn [Organon,

> Inc.]) is administered and cortisol is measured after 30 or 60 minutes

> or both. Plasma cortisol concentration of greater than 18 or 20 g/dL, at

> these times indicates adequate recovery of the

> hypothalamic-pituitary-adrenal axis [4,19].

>

> http://merck.micromedex.com/bpm/bpmviewall.asp?page=CPM02EN313

>

> I'll tell you where to go!

>

> Mayo Clinic in Rochester

> http://www.mayoclinic.org/rochester

>

> s Hopkins Medicine

> http://www.hopkinsmedicine.org

September 20, 2004