1. Taper GC dose as guided by underlying condition until 30Â mg/m2/day of hydrocortisone equivalent is reached (if taper not required for underlying condition, reduce to 30Â mg/m2/day) | |
2. Then taper by 10-20% every 3–7 days until patient is on physiological GC dose (8–10 mg/m2/day hydrocortisone equivalent) | |
3. Switch to hydrocortisone 8–10 mg/m2/day, given in the morning | |
4. Discontinue/continue hydrocortisone based on assessment of morning cortisol: | |
  < 171 nmol/L*: | HPA axis has not recovered |
→ continue daily hydrocortisone | |
→ continue stress hydrocortisone as needed | |
→ re-evaluate patient in 4–6 weeks | |
  > 500 nmol/L: | HPA axis is intact |
→ discontinue daily and stress hydrocortisone | |
  171*-500 nmol/L: | Sufficient GC production for day-to-day functioning†|
Further evaluation required to determine if stress dosing required: | |
→ discontinue daily hydrocortisone | |
→ continue stress dosing as needed | |
→ low-dose ACTH stimulation testing | |
↓ | |
If with ACTH testing: | |
  Peak cortisol > 500 nmol/L: | HPA axis is 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 |