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Managing glucocorticoid withdrawal to prevent adrenal insufficiency (DRAFT)

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Overview

The physiological equivalent dose of steroid, is the dose of glucocorticoid that is equivalent to the amount that a health adrenal gland would normally produce:

For people aged 16 years and over, this is a total daily dose of hydrocortisone 15-25mg, prednisolone 3-5mg, or dexamethasone 0.5mg

For people who have been taking glucocorticoids to treat an underlying condition for more than 4 weeks, but less than 12 weeks AND they no longer need them:

Reduce glucocorticoids to a daily physiological equivalent dose
The speed with which this is done will depend on the underlying condition for which glucocorticoids are being used but in theory, weaning to physiological equivalent dose can be rapid without causing adrenal insufficiency
Reduce further by using the same dose every other day for 2 weeks, then twice a week for 2 weeks then stopping
Decisions to taper dosages of glucocorticoid should be made by the clinical team that initiated the treatment

For people who have been taking glucocorticoids for more than 12 weeks:

After reducing to a daily physiological equivalent dose, consider stopping treatment using a slower dose-tapering regimen than in the recommendation above – see an example of slower Prednisolone wean below:

Week	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday	Sunday
0	4	4	4	4	4	4	4
1	4	3	4	3	4	3	4
2	3	3	3	3	3	3	3
3	3	2	3	2	3	2	3
4	2	2	2	2	2	2	2
5	2	1	2	1	2	1	2
6	1	1	1	1	1	1	1
7	1	0	1	0	1	0	1
8	0	0	0	0	0	0	0

In patients on dexamethasone, consider changing to prednisolone to manage dose tapering. This is because dexamethasone is significantly more potent and has a longer half-life, so it is difficult to give a corticosteroid-free period over 24 hours, which is not enough for the hypothalamic-pituitary-adrenal axis to recover.
Advise patients who are tapering glucocorticoid doses below a physiological equivalent dose:
- That they might expect temporary symptoms, including fatigue, reduction in appetite and low mood
- If at any point symptoms occur, pause at that dose until symptoms settle, and then continue the wean
- To continue to follow sick day rules advice for illness, surgery or invasive procedures whilst weaning the dose:
  - UHB - Patient Leaflet - Information for endocrine patients taking replacement steroid medication.
- Once illness improves, go straight back down to the level of steroid prior to the dose increase and continue to wean

Monitor people on glucocorticoid dose tapering below physiological equivalent dose regimens for signs and symptoms of adrenal insufficiency and provide advice to family and carers about potential symptoms to expect – see adrenal insufficiency guideline.

Who to refer

Consider a 9am serum cortisol assessment for adrenal insufficiency only when a slower dose-tapering regimen has been used AND the person has developed signs and symptoms of suspected adrenal insufficiency
When assessing a 9am cortisol level, hold the steroids for 24 hours before the test
See suspected adrenal insufficiency guidance for advice on how to interpret the 9am cortisol result.

Services

Endocrinology NBT

Endocrinology UHBW

Resources

References

Efforts are made to ensure the accuracy and agreement of these guidelines, including any content uploaded, referred to or linked to from the system. However, BNSSG ICB cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.

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