Approach to discontinuing systemic glucocorticoid therapy in adults and adolescents who have completed linear growth

ACTH: adrenocorticotropic hormone; AI: adrenal insufficiency; IV: intravenous.

* In adults, a supraphysiologic dose is considered to be equal to approximately >5 mg/day of prednisone, >0.25 mg/day of dexamethasone, or >15 mg/day of hydrocortisone.

¶ An alternative approach is to regularly check laboratory testing to diagnose and monitor AI and taper the glucocorticoid dose accordingly. If performed, testing for AI begins with holding a morning glucocorticoid dose (if this can be done safely) and checking a 7 to 9 AM cortisol level. If this is inconclusive, a plasma corticotropin (ACTH) stimulation test may be performed. For details about these tests, refer to UpToDate content on the treatment of AI.

Δ Stress dose-glucocorticoids are higher doses that are given in case of illness, trauma, or surgery. Patients should also receive education on communicating about AI to medical professionals (eg, use of medical alert tags). For more information on stress-dose glucocorticoids, refer to UpToDate content on the treatment of AI.

◊ Patients at risk of disease recurrence include those in whom glucocorticoids are treating a chronic condition (eg, rheumatoid arthritis, chronic obstructive pulmonary disease). Patients not at risk of recurrence include those treated for a self-limited condition (eg, chemotherapy-induced nausea, hypersensitivity reaction).

§ Examples of severe diseases treated with glucocorticoids include vasculitis with pulmonary or kidney involvement, life-threatening manifestations of systemic lupus erythematosus, and macrophage activation syndrome.

¥ If the glucocorticoid regimen involves 1 dose per day, give this dose in the morning to mimic the diurnal pattern of cortisol production. If multiple daily doses, give the highest dose in the morning. There is no specific dose at which the taper should end; often this is determined by common medication formulations. As glucocorticoid doses are reduced, patients should be monitored for symptoms of glucocorticoid withdrawal and AI; refer to separate algorithm on the monitoring for and management of complications during systemic glucocorticoid withdrawal.

‡ Another approach is to alternate taking a moderate dose with a reduced dose every other day.

† In adults, a physiologic replacement dose is approximately 5 to 7.5 mg/day of prednisone, 0.25 to 0.5 mg/day of dexamethasone, or 15 to 25 mg/day of hydrocortisone.