Table 13 Prednisone tapering regimen for adults

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 20 mg once-daily, given in the morning

3. Gradually reduce hydrocortisone dose by 2.5 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

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