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Is there a safe and effective way to wean patients off long-term glucocorticoids
  • Emma Baker
Emma Baker
St George's University of London
Author Profile

Abstract

Glucocorticoids are highly effective medicines in the treatment of inflammatory disorders. However they cause severe dose-related adverse reactions, particularly where taken systemically for prolonged periods. Systemic glucocorticoids are therefore given at dosage sufficient to control the disease, then withdrawn as fast as is possible to minimise dose-related adverse effects without losing disease control. End-of-use adverse reactions present a major challenge in the withdrawal of long term (>3 weeks) glucocorticoids. Suppression of the hypothalamic-pituitary-adrenal (HPA) axis causes adrenal insufficiency, which is potentially life threatening and can become symptomatic as treatment is withdrawn. Adrenal insufficiency can be extremely difficult to differentiate from ‘glucocorticoid withdrawal syndrome’, where patients experience symptoms despite adequate adrenal function, and from psychological dependence. Long term systemic glucocorticoids should therefore be withdrawn slowly. The rate at which the dose is tapered should initially be determined by treatment requirements of the underlying disease. Once physiological doses (prednisolone 7.5mg or equivalent) are reached, the rate of reduction is determined by rate of HPA recovery and need for exogenous glucocorticoid cover while endogenous secretion recovers. If symptoms prevent treatment withdrawal, HPA testing should be used to look for adrenal insufficiency. Patients with adrenal insufficiency require physiological doses of glucocorticoids for adrenal replacement, which may be lifelong if the HPA axis fails to recover.

Peer review status:Published

03 Jul 2020Submitted to British Journal of Clinical Pharmacology
15 Jul 2020Submission Checks Completed
15 Jul 2020Assigned to Editor
16 Jul 2020Reviewer(s) Assigned
29 Jul 2020Review(s) Completed, Editorial Evaluation Pending
31 Jul 2020Editorial Decision: Revise Minor
22 Sep 20201st Revision Received
23 Sep 2020Assigned to Editor
23 Sep 2020Submission Checks Completed
23 Sep 2020Review(s) Completed, Editorial Evaluation Pending
24 Sep 2020Reviewer(s) Assigned
30 Sep 2020Editorial Decision: Revise Minor
09 Nov 20202nd Revision Received
09 Nov 2020Assigned to Editor
09 Nov 2020Submission Checks Completed
09 Nov 2020Review(s) Completed, Editorial Evaluation Pending
12 Nov 2020Editorial Decision: Accept
Dec 2020Published in British Journal of Clinical Pharmacology. 10.1111/bcp.14679