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June 30, 2005
Steroid Tapering Protocol

I recently had my preceptor pimp me on the exact protocol for steroid tapering.  Of course, I hadn't a clue.  So here is some info that I found.

Indications for Steroid Withdrawal:

  • max benefit reached
  • no benefit appreciated
  • side effects too great (osteoperosis, HTN)

Immediate indications for steroid withdrawal without tapering:

  • steroid induced psychosis
  • Herpes induced corneal ulceration

Pharmacokinetics:

For the PharmDs among us...

  • age and clearance of steroid are inversely related, ie. dose elderly relatively smaller
  • slower clearance rates of steroids in Africans vs. Caucasians 

Basiclally, the protocol for steriod tapering is generalyl stratified into three broad categories of likeliness of Hypothalamic Pituitary Adrenal Axis Suppression (HPA).  Suppression can lead to adrenal insufficiency (bad).   Basically, it depends on: potency, dose, and duration of the steroid.

Likely HPA suppression:

  • 20 mg/day prednisone > 3 wks
  • evening/bedtime dosing
  • Cushingnoid appearance
  • Taper indicated!

Unlikely suppression:

  • any dose < 3 wks
  • daytime dose therapy
  • <5mg/day prednisilone
  • No taper indicated!

Uncertain suppression (gray area):

  • 10-20mg/day prednisone/day >3wks
  • <10 mg day Not at bedtime dose
  • DO: Stress test with glucorticoids OR ACTH stimulation test for further guidance on tapering

Basically, tapering is controversial depending on the study you look at and the disease you look at.  In a study of pts with asthma, COPD, Crohns, Graft vs. Host disease, tapering showed no difference.  However, in another study of children with nephrotic syndrome, a rapid taper led to a significantly higher relapse rate than a slow taper.

Paper on Glucorticoid Withdrawal by Daniel Furst.  Must have secure login first.

https://nsas1.amc.edu/get/uri/http://www.utdol.com/application/topic.asp?file=tx_rheum/5199&type=A&selectedTitle=1~14

Posted At : 8:14 AM. | Link | Rotation 6 04-05 | Comments (1)

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Comments

That's interesting that a taper is not neccessary with <3 weeks of treatment - it seems like from what I've seen they always do a taper anyway.

Posted By Eleanor Slater / Posted At 7/10/05 4:35 PM