Tapering Prednisone in Patients With SLE

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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

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.

MG, Byrne AJ. An ian crisis complicating anaesthesia.

Anaesthesia. 1981;36:681-684.

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