INFO - Tapering prednisone in patients with SLE

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Medscape Rheumatology

Ask the Experts about New Therapies for Rheumatic Disease

June 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

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

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