Glucocorticoids discontinuation

Understand that recovery of the HPA axis may take up to a year after glucocorticoid discontinuation during which the patient may require supplementation therapy during periods of physiologic stress. 

Fhtients may require a lower dose of glucocorticoid than those with primary adrenal insufficiency. Some patients will only require glucocorticoid replacement temporarily, which can be discontinued after recovery of the HPA axis (e.g., drug-induced adrenal insufficiency, adrenal insufficiency following treatment for Cushing s syndrome). 

If the patient requires discontinuation from chronic treatment with supraphysiologic doses of glucocorticoid, the following discontinuation protocol can be used 4... 

Monitor morning cortisol or response to ACTH stimulation every 3 to 6 months to assess for HPA axis recovery. Discontinue glucocorticoid replacement therapy when cortisol concentrations are greater than 19 mcg/dL (524 nmol/L) on either test. 

Cardiovascular Keep doses of NSAIDs and glucocorticoids low, consider initiation of folic acid to reduce homocysteine level elevations induced by methotrexate, consider initiation of low-dose aspirin and/or HMG-CoA reductase inhibitors (statins), and encourage smokers to discontinue tobacco use and assist with the development of a tobacco-cessation plan.11,12... 

Osteoporosis Encourage patients to ingest adequate amounts of calcium and vitamin D, encourage smokers to discontinue tobacco use, and consider initiation of medications for osteoporosis (e.g., bisphosphonates, calcitonin, and parathyroid hormone) if the patient is taking glucocorticoids for an extended period of time or if the patient has evidence of low bone mineral density.15,41... 

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. 

Rapid progression of Kaposi s sarcoma 10 weeks after combined treatment with glucocorticoids and cyclophosphamide has been described marked improvement of the skin lesions was noted after discontinuation of prednisone therapy (360). 

Czachur M. Changes in bone mineral density following discontinuation or continuation of alendronate therapy in glucocorticoid-treated patients a retrospective, observational study. Arthritis Rheum 2003 48 1102-8. 

Eight patients with steroid-dependent asthma, who had been able to either discontinue or reduce their oral glucocorticoid requirement subsequent to starting treatment with zafirlukast, developed Churg-Strauss syndrome (7). 

A 36-year-old woman developed a generalized rash, severe itching with erythema, and papules 4 days after discontinuing a kava formulation (Antares), which she had taken in a dosage of 120 mg/day for 3 weeks (19). The condition improved with glucocorticoids and antihistamines, but the itching lasted several weeks. Patch tests with the kava extract were positive. 

Treatment of these problems is by substituting another insulin species which does not cross-react with the antibodies, by desensitization, or by local or systemic administration of glucocorticoids. If a severe allergic reaction occurs, the drug has to be discontinued and the patient treated with the usual agents (e.g. adrenaline, antihistamines or corticosteroids). Patients who have experienced severe systemic allergic symptoms should be skin-tested with another insulin preparation before its initiation. Desensitization procedures may permit resumption of insulin administration. 

The most frequent adverse event associated with nevirapine is rash, which occurs in approximately 16% of patients. Mild macular or papular eruptions commonly involve the trunk, face, and extremities and generally occur within the first 6 weeks of therapy. Pruritus is also common. In the majority of patients, the rash resolves with continued administration of drug. Up to 7% of patients discontinue therapy owing to rash, and administration glucocorticoids may cause a more severe rash. Life-threatening Stevens-Johnson syndrome is rare but occurs in up to 0 3% of recipients. 

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