Glucocorticoid tapering

Figure 2 Chest CT scan cavitary lung masses. A 35-year-old woman with a 9-year history of relapsing WG. The left panel shows bilateral lung masses with and without cavitation at the time of disease flare before treatment. Because of multiple drug tox-icities, remission induction therapy for this flare consisted of prednisone and rituximab (4 weekly infusions of 375 mg/m ). The right panel shows the follow-up CT scan after completion of the glucocorticoid taper.

Gradually taper the dose to approximately 20 mg of prednisone or equivalent per day, given in the morning, then ° Change glucocorticoid to every other day administration, in the morning. 

Attempt to taper glucocorticoid if Cushing s syndrome is from exogenous administration. 

Intraarticular injections of depot forms may be useful when only a few joints are involved. If effective, injections may be repeated every 3 months. No one joint should be injected more than two or three times per year. Adverse effects of systemic glucocorticoids limit their long-term use. Dosage tapering and eventual discontinuation should be considered at some point in patients receiving chronic therapy. 

Hydrocortisone given parenterally is the corticosteroid of choice because of its combined glucocorticoid and mineralocorticoid activity. The starting dose is 100 mg IV by rapid infusion, followed by a continuous infusion or intermittent bolus of 100 to 200 mg every 24 hours. IV administration is continued for 24 to 48 hours. If the patient is stable at that time, oral hydrocortisone can be started at a dose of 50 mg every 8 hours for another 48 hours. A hydrocortisone taper is then initiated until the dosage is 30 to 50 mg/day in divided doses. 

The use of glucocorticoids for tuberculous meningitis remains controversial. The administration of steroids such as oral prednisone, 60 to 80 mg/ day (1 to 2 mg/kg/day in children), or 0.2 mg/kg/day of IV dexametha-sone, tapered over 4 to 8 weeks, improves neurologic sequelae and survival in adults and decrease mortality, long-term neurologic complications, and permanent sequelae in children. 

When corticosteroids are administered for more than 2 weeks, adrenal suppression may occur. If treatment extends over weeks to months, the patient should be given appropriate supplementary therapy at times of minor stress (two-fold dosage increases for 24-48 hours) or severe stress (up to ten-fold dosage increases for 48-72 hours) such as accidental trauma or major surgery. If corticosteroid dosage is to be reduced, it should be tapered slowly. If therapy is to be stopped, the reduction process should be quite slow when the dose reaches replacement levels. It may take 2-12 months for the hypothalamic-pituitary-adrenal axis to function acceptably, and cortisol levels may not return to normal for another 6-9 months. The glucocorticoid-induced suppression is not a pituitary problem, and treatment with ACTH does not reduce the time required for the return of normal function. 

Glucocorticoids are commonly used in the treatment of patients with moderate to severe active inflammatory bowel disease. Active disease is commonly treated with an initial oral dosage of 40-60 mg/d of prednisone or prednisolone. Higher doses have not been shown to be more efficacious but have significantly greater adverse effects. Once a patient responds to initial therapy (usually within 1-2 weeks), the dosage is tapered to minimize development of adverse effects. In severely ill patients, the drugs are usually administered intravenously. 

The use of postnatal glucocorticoids in very premature infants is controversial although dexamethasone reduces bronchopulmonary dysplasia, it has been associated with severe adverse effects (407). In 220 infants with a birth-weight of 501-1000 g randomized to placebo or dexamethasone (0.15 mg/kg/day for 3 days and tapering over a period of 7 days) the relative risk of death or chronic lung disease... 

A 57-year-old man took prednisone 20-30 mg/day for 13 years for rheumatoid arthritis (45). He had been treated unsuccessfully with gold, azathioprine, hydroxychloroquine, and sulfasalazine tapering his glucocorticoid dosage had been unsuccessful. He developed worsening back pain in his thoracic spine and lateral... 

A 17-year-old boy, with an 11-year history of asthma, had anaphylaxis with respiratory distress shortly after he received intravenous methylprednisolone for an exacerbation of asthma while taking a tapering course of oral prednisone 15 mg/day (259). He had been glucocorticoid-dependent for at least 1 year. He reported having received intravenous glucocorticoids previously. He was treated with inhaled salbutamol and then intravenous methylprednisolone 125 mg over 15-30 seconds, and 3-4 minutes later became flushed and dyspneic, and developed diffuse urticarial lesions on his trunk and face and an undetectable blood pressure. He was treated with adrenaline, but required intubation. Sinus bradycardia developed and then asystole. He was successfully resuscitated and a 10-15 seconds period of generalized tonic-clonic activity was treated with diazepam. He remained unresponsive to stimulation for... 

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