Introduction: Prolonged therapy with high-dose corticosteroids (≥ 7.5 mg Prednisolone or 11.5 mg Dexamethasone daily) can result in adrenal atrophy and hypofunction. Abrupt withdrawal of corticosteroids after prolonged use can lead to adrenal insufficiency, corticosteroid withdrawal symptoms or a relapse of the initial disease. There are several in-house protocols for safe corticosteroid dose tapering but a national protocol is required.
Our protocol: Patients are informed of the problems that may be encountered during corticosteroid withdrawal after short-term, intermediate-term and long-term use: namely symptoms of adrenal insufficiency, corticosteroid-withdrawal or relapse of the initial disease for which the corticosteroid was started. Recovery of the adrenal gland function can be very slow if there is going to be any recovery at all. High doses of corticosteroids can be rapidly reduced over 14 weeks to a Prednisolone equivalent of 7.5 mg daily depending on symptoms. Some physicians may convert to Hydrocortisone at this stage. Otherwise we reduce the Prednisolone dose by 0.5 mg every month depending on symptoms. Once the patient is on 33.5 mg daily we arrange a Short Synacthen test to assess adrenal gland function on a morning before Prednisolone ingestion. This can also be done after a weekend conversion to Hydrocortisone. If adrenal gland function is normal we stop or continue to tail down the Prednisolone dose according to symptoms. If adrenal function is still subnormal the patient can stay on the same dose or a higher dose depending on symptoms. A repeat Short Synacthen test after 23 months will help decide if patient should stay on lifelong physiological-dose corticosteroid replacement.
Conclusion: Our protocol ensures the provision of adequate information to the patient concerning the problems of corticosteroid withdrawal after prolonged use, a safe and flexible corticosteroid withdrawal regimen, and ensures regular adrenal function assessment during and after successful corticosteroid withdrawal.