Exogenous glucocorticoids lead to suppression of the HPA axis via negative feedback on the hypothalamus and pituitary and may be associated with increased morbidity and mortality (Wei L. Ann Intern Med. 2004). Many patients whose steroids are no longer required for their underlying disease find withdrawal challenging. Presentations: Case 1: 68-year old male treated with steroids for hepatic graft versus host disease following a stem cell transplant for EBV-lymphoproliferative disease 6 years previously. He remained on a total daily dose of 25 mg hydrocortisone, but no longer required immunosuppression. Case 2: 55-year old female treated with glucocorticoids since vocal cord resection 7 months previously was taking 9 mg daily prednisone at our assessment. Case 3: 39-year old female treated with prednisone, up to 100 mg daily over 6 years for autoimmune ocular disease (Vogt-Koyanagi-Harada syndrome), complicated by avascular necrosis of the hip. By our assessment, she had decreased to 5 mg prednisone daily, but felt tired with further attempted reduction. Intervention: All patients were treated with hydrocortisone three times daily, initially at daily doses equivalent to their previous glucocorticoids. Written schedules with reduction of 2.5 mg daily hydrocortisone every two weeks were provided. 250 μg ACTH-stimulation tests were performed when the patients reached sub-physiological hydrocortisone doses. Response: Cases 1 and 2 successfully withdrew from glucocorticoids over 5 and 7 months respectively. After 5 months case 3 was down to 10 mg daily hydrocortisone and ACTH-stimulation test showed a suboptimal response (peak serum cortisol 348 pmol/l). Therefore hydrocortisone was continued at 10 mg daily and ACTH-stimulation test will be repeated in 3 months. Discussion: Patients may withdraw successfully from prolonged glucocorticoid therapy with gradual reductions and may benefit from written instructions. Our patient with the slowest recovery (still ongoing) had been on the highest dose of glucocorticoids. We favour a short-acting glucocorticoid, such as hydrocortisone, for the withdrawal period.
Declaration of interest: There is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported.
Funding: Declaration of Funding: This work was supported by the intra mural program of the Eunice Kennedy Shriver National Institute of Child Health and Human Development.