- 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:To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- Kirwan JR. Systemic corticosteroids in rheumatology. In: Rheumatology, Hochberg MC, Silman AJ, Smolen JS (Eds), Mosby, St. Louis 2003. p.385.
- Francisco GE, Honigberg IL, Stewart JT, et al. In vitro and in vivo bioequivalence of commercial prednisone tablets. Biopharm Drug Dispos 1984; 5:335.
- Garg DC, Wagner JG, Sakmar E, et al. Rectal and oral absorption of methylprednisolone acetate. Clin Pharmacol Ther 1979; 26:232.
- Rose JQ, Yurchak AM, Jusko WJ, Powell D. Bioavailability and disposition of prednisone and prednisolone from prednisone tablets. Biopharm Drug Dispos 1980; 1:247.
- Legler UF, Benet LZ. Marked alterations in dose-dependent prednisolone kinetics in women taking oral contraceptives. Clin Pharmacol Ther 1986; 39:425.
- Toothaker RD, Craig WA, Welling PG. Effect of dose size on the pharmacokinetics of oral hydrocortisone suspension. J Pharm Sci 1982; 71:1182.
- Pickup ME, Lowe JR, Leatham PA, et al. Dose dependent pharmacokinetics of prednisolone. Eur J Clin Pharmacol 1977; 12:213.
- Hill MR, Szefler SJ, Ball BD, et al. Monitoring glucocorticoid therapy: a pharmacokinetic approach. Clin Pharmacol Ther 1990; 48:390.
- Tornatore KM, Logue G, Venuto RC, Davis PJ. Pharmacokinetics of methylprednisolone in elderly and young healthy males. J Am Geriatr Soc 1994; 42:1118.
- Tornatore KM, Biocevich DM, Reed K, et al. Methylprednisolone pharmacokinetics, cortisol response, and adverse effects in black and white renal transplant recipients. Transplantation 1995; 59:729.
- Kimball CP. Psychological dependency on steroids? Ann Intern Med 1971; 75:111.
- Dixon RB, Christy NP. On the various forms of corticosteroid withdrawal syndrome. Am J Med 1980; 68:224.
- Volkmann ER, Rezai S, Tarp S, et al. We still don't know how to taper glucocorticoids in rheumatoid arthritis, and we can do better. J Rheumatol 2013; 40:1646.
- Richter B, Neises G, Clar C. Glucocorticoid withdrawal schemes in chronic medical disorders. A systematic review. Endocrinol Metab Clin North Am 2002; 31:751.
- Brignola C, De Simone G, Belloli C, et al. Steroid treatment in active Crohn's disease: a comparison between two regimens of different duration. Aliment Pharmacol Ther 1994; 8:465.
- Hings IM, Filipovich AH, Miller WJ, et al. Prednisone therapy for acute graft-versus-host disease: short- versus long-term treatment. A prospective randomized trial. Transplantation 1993; 56:577.
- Ueda N, Chihara M, Kawaguchi S, et al. Intermittent versus long-term tapering prednisolone for initial therapy in children with idiopathic nephrotic syndrome. J Pediatr 1988; 112:122.
- Byyny RL. Withdrawal from glucocorticoid therapy. N Engl J Med 1976; 295:30.
- Nelson AM, Conn DL. Series on pharmacology in practice. 9. Glucocorticoids in rheumatic disease. Mayo Clin Proc 1980; 55:758.
- 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