Approach to discontinuing systemic glucocorticoid therapy in children who have not completed linear growth

This algorithm represents a general approach to patients in whom glucocorticoid therapy may be nonurgently discontinued. Discontinuing systemic glucocorticoids should accommodate convenient dosing and individual patient factors and response. As examples, a faster taper may be preferred in the presence of significant adverse drug effects or comorbid conditions worsened by systemic glucocorticoids, while a slower taper may be preferred when treating patients with severe underlying disease (eg, life-threatening manifestations of systemic rheumatic diseases), high risk of disease recurrence with taper, history of severe glucocorticoid withdrawal with taper, or unstable clinical status. As glucocorticoid doses are reduced, patients should be monitored for symptoms of glucocorticoid withdrawal and adrenal insufficiency. Dosing of glucocorticoids in infants and children is based on BSA, calculated based on height and weight. A BSA calculator (Mosteller, square root method) is available in UpToDate. For additional information on discontinuing systemic glucocorticoids that were used to treat a specific disease, please refer to the disease-specific treatment topic.

ACTH: adrenocorticotropic hormone; AI: adrenal insufficiency; BSA: body surface area; IV: intravenous.

* 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.

¶ Stress dose-glucocorticoids are higher doses that are given in case of illness, trauma, or surgery. Patients should 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.

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

◊ If the glucocorticoid regimen involves 1 dose per day, it should be taken in the morning to mimic the diurnal pattern of cortisol production. If multiple daily doses, the highest dose should be taken in the morning.

§ Hydrocortisone is preferred due to ease of administering smaller doses and lower risk of growth suppression. However, use of hydrocortisone may not be possible when other aspects of a particular glucocorticoid are preferred (eg, improved central nervous system penetration with dexamethasone, availability of liquid formulations such as prednisolone).

¥ Hydrocortisone is generally given as 2 to 3 divided doses per day (eg, two-thirds of the daily dose in the morning and one-third of the dose in the afternoon/evening; or half of the daily dose in the morning, one-quarter at midday, and one-quarter in the evening).

‡ There is no specific dose at which the taper should end; often this is determined by common medication formulations (eg, nonstandard formulations may be required to administer hydrocortisone doses <2.5 mg/day because the smallest tablet size is 5 mg). We monitor clinically for evidence of AI and counsel patients about this risk and the ongoing use of stress-dose glucocorticoids. Some experts perform laboratory testing for AI several months after discontinuing glucocorticoids to formally test for adrenal gland recovery.

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

Graphic 148782 Version 2.0

UpToDate خرید پکیج

Approach to discontinuing systemic glucocorticoid therapy in children who have not completed linear growth

خرید پکیج