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The CSM has recommended that gradual withdrawal of systemic corticosteroids should be considered in those whose disease is unlikely to relapse and have:
Systemic corticosteroids may be stopped abruptly in those whose disease is unlikely to relapse and have received treatment for 3 weeks or less and are not included in the patient groups described above.
During corticosteroid withdrawal the dose may be reduced rapidly (e.g. 5mg per day) down to physiological doses (equivalent to prednisolone 7.5mg daily) and then reduced more slowly (e.g. 1-2mg per week). Assessment of the disease may be needed during withdrawal to ensure that relapse does not occur.
To compensate for a diminished adrenocortical response caused by prolonged corticosteroid treatment, any significant intercurrent illness, trauma or surgical procedure requires a temporary increase in corticosteroid dose (determined by starting dose), or if already stopped, a temporary re-introduction of corticosteroid treatment. Anaesthetists must therefore know whether a patient is taking or has been taking a corticosteroid, to avoid a precipitous fall in blood pressure during anaesthesia or in the immediate post-operative period.
In the management of Addison's disease, physiological replacement is best achieved with a combination of hydrocortisone and the mineralocorticoid fludrocortisone (see section 6.3.1 Replacement therapy); hydrocortisone alone does not usually provide sufficient mineralocorticoid activity for complete replacement.
In the management of hypopituitarism, which is more common, hydrocortisone alone may often prove sufficient.
The optimum daily dose is determined on the basis of clinical and biochemical response.
If a patient is suffering with an infection which leaves them bed-bound, the glucocorticoid should be doubled for several days. If the patient is vomiting, then the use of intramuscular hydrocortisone is indicated.
Glucocorticoids, notably prednisolone, are used as anti-inflammatory agents in many areas of medicine. These drugs suppress the response of B cells of the immune system and affect the inflammatory process at an early stage.
Adrenal suppression and increased risk of infection can occur whilst taking these drugs and the steroid warning card should be issued with all prescriptions.
Live vaccines should be avoided with immunosuppressive doses.
Prednisolone 5mg =
Patients on long-term corticosteroid treatment should carry a steroid treatment card which gives guidance on minimising risk and provides details of prescriber, drug, dosage and duration of treatment.