Corticosteroid therapy

Weaning a patient who has been on therapy for protracted periods — how slow and how low is it safe to go?

The higher the maintenance dose the slower the taper should be and the less likely it will be to discontinue therapy completely. That is intuitively obvious, but it would be helpful to have access to more specific instructions. Regrettably I could find no evidence-based guidelines that address this topic. Hopefully one or more readers can point me to the best sources. Let the patient be your guide. In some circumstances, the taper may result in an exacerbation of the condition for which steroids were prescribed. That’s a clear message to stop the taper for now and try again later.

When there is no such exacerbation the patient is still the best guide as she/he will let you know when things don’t feel quite right. Go back to the previous dose that was well tolerated by the patient and stay on that dose for two to three weeks before trying again. Some (many?) patients cannot just be weaned to a dose equivalent to 20 mg per day of hydrocortisone.

Patients who can be successfully weaned off steroids need to remain conscious of their previous prolonged use of steroids. I advise my patients to wear a Medic Alert tag around their neck indicating previous steroid use in case they find themselves in an emergency situation. Giving stress doses of steroids may be life saving. I used to suggest either a tag or a bracelet until a recent patient found herself in such a situation, but EMS did not notice her bracelet as they focused on her cardiac symptoms. Yes, her radial pulse was checked but not on the wrist with the bracelet.

Another corticosteroid issue for which I could not find clinical practice guidelines was adrenal insufficiency. Just how much or how little should you be prescribing routinely? The time-honored regimen is 10 mg in the morning and 5 mg in the afternoon. Others have suggested just 5 mg twice a day. That may well be enough for some patients and the lowest practical dose of any medication always makes sense. Patients for whom 5 mg and 5 mg is not enough will let you know that they start to drag in mid-afternoon. Patients with adrenal insufficiency should also be advised to wear a tag. They also need to be empowered to take an extra dose, probably double their regular dose, whenever they have an intercurrent illness and should also take a repeat dose if they experience any vomiting.

Whenever I am asked whether a patient who has been on steroid therapy in the past should be given stress doses of steroids for elective surgery, my response is almost always yes. The potential harm from not giving steroids — albeit small in most of these patients — is less than the potential for benefit. I can find no specific guidelines addressing this topic. An adrenocorticotropic hormone stimulation test with a normal cortisol response might suggest that stress-dose steroids are not necessary, but there will always be a lingering doubt if things don’t go well.

Finally some guidelines! Critical Care Medicine reported very comprehensive evidence-based guidelines for diagnosis and management of corticosteroid insufficiency in critically ill patients. “The task force coined the term critical illness-related corticosteroid insufficiency to describe the dysfunction of the hypothalamic-pituitary-adrenal axis that occurs during critical illness. Critical illness-related corticosteroid insufficiency is caused by adrenal insufficiency together with tissue corticosteroid resistance and is characterized by an exaggerated and protracted pro-inflammatory response.” This excellent document includes too much detail to provide details here, and I have to assume that those guidelines have become standard of care in the ICU.

There are also guidelines for skeletal protection in patients receiving long-term steroid therapy for a variety of conditions. Regrettably there is even bigger literature pointing out that these guidelines are not followed as often as 50% of the time. Steroids are among the most detrimental drugs as far as skeletal health is concerned since the effect is to both stimulate bone resorption and inhibit bone formation.

Marik PE. Crit Care Med. 2008;36:1937-1949. PMID: 18496365.