1. Reduce dose by 2.5- to 5.0-mg decrements every 3–7 days until physiologic dose (5 to 7.5 mg of prednisone per day) is reached; slower tapering of GC therapy may be recommended if risk of disease relapse is a concern | |
2. Switch to hydrocortisone 20Â mg once-daily, given in the morning | |
3. Gradually reduce hydrocortisone dose by 2.5Â mg over weeks to months | |
4. Discontinue/continue hydrocortisone based on assessment of morning cortisol: | |
  < 85 nmol/L: | HPA-axis has not recovered |
→ continue hydrocortisone | |
→ re-evaluate patient in 4–6 weeks | |
  85-275 nmol/L: | Suspicious for AS |
→ Continue hydrocortisone | |
→ Further testing of HPA axis or re-evaluate in 4–6 weeks | |
→ If further evaluation of HPA axis is selected: | |
 ▪ ITT (gold-standard but not widely available) | |
 ▪ ACTH stimulation testing (see below) | |
  276-500 nmol/L: | HPA-axis function is likely adequate for daily activities in a non-stressed state, but may be inadequate for preventing adrenal crisis at times of stress or illness |
 | → Discontinue hydrocortisone |
 | → Monitor for signs & symptoms of AS |
 | → Consider further evaluation of HPA axis to determine if function is also adequate for stressed states or consider empiric therapy with high-dose steroids during times of stress |
  > 500 nmol/L: | HPA axis is intact |
→ discontinue hydrocortisone | |
↓ | |
If ACTH stimulation testing is performed and: | |
Peak cortisol rises to > 500 nmol/L: | HPA axis intact and GC can be discontinued |
Peak cortisol < 500 nmol/L: | Steroids required at times of stress and illness until normal ACTH response is noted |