INFO - Tapering prednisone in patients with SLE

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From Medscape Rheumatology

Posted 06/05/2006

Tapering Prednisone in Patients With SLE

Question

My patient has been taking prednisone 10 mg a day for the past year, for

SLE. Can you advise on the recommended taper procedure?

Ayotte, MD

Response from I. Fox, MD, PhD

Member, Rheumatology and Medicine Department, Scripps Memorial Hospital, La

Jolla, California

The risks of tapering steroids in a patient on a dose of 10 mg per day for 1

year should be small if the steroids are tapered gradually. At our clinic,

we would initially drop to prednisone 7.5 mg per day for 2 weeks and then

further taper by 1 mg per week until patient is off the medication.

Comment:

The question of steroid dependency is a difficult clinical and potential

medical-legal problem. Consideration of adrenal insufficiency during stress

as well as infection and anesthesia at surgery need to be considered as the

steroids are tapered.

Suppression of the hypothalamic-adrenal axis (HPA) needs to be considered in

a patient who has received a glucocorticoid dose comparable to more than 20

mg of prednisone a day for more than 3 weeks. Any patient who has a

cushingoid appearance must also be considered at increased risk.

Patients who have an intermediate or uncertain risk of HPA suppression

include those with the following characteristics: those taking 10-20 mg of

prednisone per day for more than 3 weeks and any patient who has taken less

than 10 mg of prednisone or its equivalent per day, providing that it is not

taken as a single bedtime dose for more than a few weeks.

If withdrawal from glucocorticoids is otherwise indicated, gradual reduction

in dose is appropriate for these patients with an intermediate or uncertain

risk of HPA suppression. Such patients do not need to be tested for HPA

functional reserve unless abrupt discontinuation is being considered or the

patient is facing an acute stress such as surgery. In the latter case, one

can give stress doses of glucocorticoids.

Identifying the degree of HPA suppression is not simple clinically. Thus, in

practice it is unusual to perform any testing of HPA function before

beginning the glucocorticoid withdrawal process. However, as noted

previously, in certain settings (eg, the patient for whom elective surgery

is planned) such testing may be warranted.

The response to administration of synthetic adrenocorticotropic hormone

(cosyntropin) is the preferred method to assess adrenocortical function.

Although the cosyntropin test does not provide information about

hypothalamic function, it has the advantage that it can be performed in the

office or clinic setting over 1 hour. Test results should be available

within hours to days thereafter.

Testing for HPA function is appropriate when patients are using 5 mg/day of

prednisone and there is difficulty reducing the dose further because of

non-disease-related symptoms. If adrenocorticotropic hormone stimulation

testing indicates normal adrenal responsiveness but a patient continues to

have non-disease-related symptoms with further attempts to reduce

glucocorticoid dosing, then corticotrophin-releasing hormone stimulation

testing may be used. In our experience, corticotropin-releasing hormone

testing is needed on very rare occasions.

Posted 06/05/2006

--------------------------------------------------------------------------------

Suggested Readings

a.. s TP, Whitlock RT, Edsall J, Holub DA. ian crisis

while taking high-dose glucocorticoids. An unusual presentation of primary

adrenal failure in two patients with underlying inflammatory diseases. JAMA.

1988;260:2082-2084.

b.. MG, Byrne AJ. An ian crisis complicating

anaesthesia. Anaesthesia. 1981;36:681-684.

From Medscape Rheumatology

Tapering Prednisone in Patients With SLE

Question

My patient has been taking prednisone 10 mg a day for the past year, for

SLE. Can you advise on the recommended taper procedure?

Ayotte, MD

Response from I. Fox, MD, PhD

Member, Rheumatology and Medicine Department, Scripps Memorial Hospital, La

Jolla, California

The risks of tapering steroids in a patient on a dose of 10 mg per day for 1

year should be small if the steroids are tapered gradually. At our clinic,

we would initially drop to prednisone 7.5 mg per day for 2 weeks and then

further taper by 1 mg per week until patient is off the medication.

Comment:

The question of steroid dependency is a difficult clinical and potential

medical-legal problem. Consideration of adrenal insufficiency during stress

as well as infection and anesthesia at surgery need to be considered as the

steroids are tapered.

Suppression of the hypothalamic-adrenal axis (HPA) needs to be considered in

a patient who has received a glucocorticoid dose comparable to more than 20

mg of prednisone a day for more than 3 weeks. Any patient who has a

cushingoid appearance must also be considered at increased risk.

Patients who have an intermediate or uncertain risk of HPA suppression

include those with the following characteristics: those taking 10-20 mg of

prednisone per day for more than 3 weeks and any patient who has taken less

than 10 mg of prednisone or its equivalent per day, providing that it is not

taken as a single bedtime dose for more than a few weeks.

If withdrawal from glucocorticoids is otherwise indicated, gradual reduction

in dose is appropriate for these patients with an intermediate or uncertain

risk of HPA suppression. Such patients do not need to be tested for HPA

functional reserve unless abrupt discontinuation is being considered or the

patient is facing an acute stress such as surgery. In the latter case, one

can give stress doses of glucocorticoids.

Identifying the degree of HPA suppression is not simple clinically. Thus, in

practice it is unusual to perform any testing of HPA function before

beginning the glucocorticoid withdrawal process. However, as noted

previously, in certain settings (eg, the patient for whom elective surgery

is planned) such testing may be warranted.

The response to administration of synthetic adrenocorticotropic hormone

(cosyntropin) is the preferred method to assess adrenocortical function.

Although the cosyntropin test does not provide information about

hypothalamic function, it has the advantage that it can be performed in the

office or clinic setting over 1 hour. Test results should be available

within hours to days thereafter.

Testing for HPA function is appropriate when patients are using 5 mg/day of

prednisone and there is difficulty reducing the dose further because of

non-disease-related symptoms. If adrenocorticotropic hormone stimulation

testing indicates normal adrenal responsiveness but a patient continues to

have non-disease-related symptoms with further attempts to reduce

glucocorticoid dosing, then corticotrophin-releasing hormone stimulation

testing may be used. In our experience, corticotropin-releasing hormone

testing is needed on very rare occasions.

Posted 06/05/2006

--------------------------------------------------------------------------------

Suggested Readings

a.. s TP, Whitlock RT, Edsall J, Holub DA. ian crisis

while taking high-dose glucocorticoids. An unusual presentation of primary

adrenal failure in two patients with underlying inflammatory diseases. JAMA.

1988;260:2082-2084.

b.. MG, Byrne AJ. An ian crisis complicating

anaesthesia. Anaesthesia. 1981;36:681-684.

http://www.medscape.com/viewarticle/533265

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