Glucocorticoids form the mainstay of many treatment modalities in paediatrics ranging from short term use in asthma to longer term use as anti-inflammatory agents in nephrotic syndrome and rheumatoid disorders. Long term use although effective brings with it the problems of adrenal suppression.
When considering weaning a patient from glucocorticoid use consideration needs to be given to the type of glucocorticoid used, duration of treatment, dosage used and current disease activity. The speed of weaning is determined mainly by disease activity and risk of relapse. Essentially if treatment is less than 3 weeks duration glucocorticoid therapy can be stopped without weaning. If greater than 3 weeks or where there have been multiple short courses over a 12 month period then a weaning schedule is needed. Dosing can be reduced by 25% every 12 weeks depending on the underlying disease. Once the dose is down to an equivalence of 12 mg/m2 per day the glucocorticoid can be switched to hydrocortisone and the dose reduced by 2.5 mg per week until just below the normal daily production amount of 7 mg/m2 day. There is a hierarchy of hypothalamo-pituitary-adrenal recovery starting with restitution of the normal circadian rhythm followed by the stress response. This can be assessed by 24 hour profile work and synacthen stimulation. Other options for assessing recovery will be discussed. Until full recovery of both the circadian rhythm and the response to synacthen stimulation the patient should follow an emergency care plan.
22 - 24 Nov 2017
British Society for Paediatric Endocrinology and Diabetes