How to taper steroids in patients on long-term steroids with iatrogenic Cushing’s?

Patients on long-term steroid therapy should be offered withdrawal of steroid therapy in following way. There is a paucity of randomized trials which have looked at the best possible method of tapering steroids. Most are based on regimens that have been followed. Any patient with steroid use for less than 3 weeks can be stopped without tapering. Any patient on prednisolone >5 mg for >3 weeks undergoes tapering by 2.5 mg every 3–4 days till the patient is brought down to 5 mg/day. Once the patient is on 5 mg/day, the patient is shifted to the equivalent dose of hydrocortisone 20 mg as it has a shorter half-life and is easier to taper down (as compared to prednisolone). Hydrocortisone is then tapered at the rate of 2.5 mg/1–2 weeks to reach hydrocortisone 10 mg/day in the morning. At this point, the patient is maintained on hydrocortisone 10 mg/day for 2–3 months allowing the axis sufficient time to recover. At the end of 3 months, a synacthen stimulation test can be done to decide if the patient can go off steroids if they have a cortisol value >18 mg/dL. Another way of assessing recovery is doing an 8 am cortisol after omitting the hydrocortisone dose for the day. If the cortisol level >10 μg/dL steroids can be withdrawn with advice for stress dose when infections occur. Most often steroid withdrawal is far from the smooth tapering regimens we design. Conditions for which they were on steroids in the first place may flare up requiring increase  in steroid dose. Second, most patients on steroids for a long time, are used to the euphoric sense of well-being they provide and tend to take a step or two back in the tapering program without informing the clinician (Table 4.1).

In patients taking prednisolone 5–7.5 mg/d or equivalent corticosteroid, SST 12–24 hours after omitted dose of steroid to decide sudden or gradual withdrawal.