INFO - Why stopping prednisone must usually be done gradually

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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underlying illness may recur, the glucocorticoids should be withdrawn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