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Table 13 Prednisone tapering regimen for adults

From: A practical guide to the monitoring and management of the complications of systemic corticosteroid therapy

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
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
  1. AS adrenal suppression, GC glucocorticoid, HPA hypothalamic-pituitary-adrenal, ACTH adrenocorticotropic hormone, ITT insulin tolerance test.
  2. Note: Exogenous estrogen therapy increases serum cortisol; therefore, the same thresholds for diagnosing AS do not apply in the setting of estrogen use.