- Daniel E Furst, MD
Daniel E Furst, MD
- Section Editor — Treatment Issues in Rheumatology
- Clinical professor, University of Washington, Seattle
- Clinical professor, University of Florence, Florence, Italy
- Professor of Rheumatology, University of California in Los Angeles (Emeritus)
- Director of Research, Pacific Arthritis Associates
- Kenneth G Saag, MD, MSc
Kenneth G Saag, MD, MSc
- Professor of Medicine
- University of Alabama at Birmingham
Chronic glucocorticoid therapy is used in the treatment of a variety of disorders because of its potent antiinflammatory effects and, occasionally, because it is thought to have immunosuppressive activity . Among the rheumatic diseases in which glucocorticoids are often used are rheumatoid arthritis, large- and small-vessel vasculitis, systemic lupus erythematosus, polymyalgia rheumatica, and, in some cases, the arthritis associated with inflammatory bowel disease .
Despite its efficacy, steroid-induced side effects generally require tapering of the drug as soon as the disease being treated is under control. Tapering must be done carefully to avoid both recurrent activity of the underlying disease and possible cortisol deficiency resulting from hypothalamic-pituitary-adrenal axis (HPA) suppression during the period of steroid therapy. (See "Pharmacologic use of glucocorticoids", section on 'HPA axis suppression'.)
This topic discusses the major issues related to tapering, the regimen(s) we use in most patients, and other glucocorticoid tapering regimens that have been reported in the literature.
The clinical manifestations, diagnosis, and treatment of adrenal insufficiency are presented separately. (See "Clinical manifestations of adrenal insufficiency in adults" and "Treatment of adrenal insufficiency in adults".)
INDICATIONS FOR WITHDRAWING GLUCOCORTICOIDS
It is helpful to briefly review the indications for glucocorticoid withdrawal before discussing the different glucocorticoid withdrawal regimens. These indications include the following:
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- INDICATIONS FOR WITHDRAWING GLUCOCORTICOIDS
- GLUCOCORTICOID PREPARATIONS
- Steroid pharmacokinetics
- HYPOTHALAMIC-PITUITARY-ADRENAL AXIS SUPPRESSION
- Identifying patients with HPA suppression
- - HPA suppression likely
- - HPA suppression unlikely
- - Intermediate/uncertain risk of HPA suppression
- Estimation of HPA suppression
- - Low-dose ACTH stimulation test
- OTHER FORMS OF GLUCOCORTICOID DEPENDENCE
- TAPERING REGIMENS
- RECOMMENDED TAPERING REGIMEN
- Alternate-day regimen
- OTHER PUBLISHED TAPERING REGIMENS
- SUMMARY AND RECOMMENDATIONS