Clinical Myths: Corticosteroid Tapering
Can you think of other "clinical myths" that need revisiting in the cost-conscious '90s? Send your ideas to the Academics Editor.
Subacute patients are often coming off intravenous steroid therapy following surgical procedures or treatment of conditions as diverse as asthma and wounds. The traditional mantra has been that these patients required tapering of corticosteroid therapy, but recent experience indicates that this is not always necessary. In this first "clinical myths" installment of the Subacute Care Forum, I explore the need for the complicated tapering of steroids, a process that has confused many patients and practitioners.
Case History
This patient in this case study (see sidebar on next page) is status postsurgical resection of an abdominal mass in the sigmoid colon. A colostomy has been created, and the patient is receiving heparin for prevention of postsurgical emboli and postsurgical analgesics for pain.
The need for steroid tapering is questionable in this case, despite the high steroid doses.1,2 However, many clinicians still will taper following doses of this magnitude over a one- or two-week period.
Need for Steroid Tapering
Two factors lead to a need for tapering of doses: suppression of the adrenal medulla secretion of cortisol and exacerbation of inflammation upon abrupt steroid discontinuance.
The traditional view on tapering of corticosteroid therapy has emerged from the drugs' effects on corticoid secretion by the adrenal medulla. Prednisone equivalent doses of 40-60 mg/day or more for five days or longer suppress the secretion sufficiently to make abrupt discontinuance dangerous. Thus, unit-of-use packaging such as Medrol dose packs have been designed to facilitate patient compliance with a gradual cessation of therapy. However, as one author noted,1 no case reports of clinically important adrenal suppression have been reported after two weeks or less of oral therapy at doses such as prednisolone 40 mg/day. USP DI recommends tapering after high-dose therapy that lasts for five days or more, with the taper occurring over 7 to 14 days.3
In other clinical situations, the steroid dose is not high enough to suppress the adrenal medulla. Rather, the clinical condition requires gradual cessation of therapy to avoid rebound symptoms. Asthma is an excellent example of a condition requiring tapering to avoid rebound bronchospasms.1
In this patient, the need for steroid tapering is questionable for two reasons. The long-term use of prednisone 7.5 mg/day would have largely suppressed adrenal secretion of cortisol, meaning that the patient is now completely dependent on exogenous sources. Since the high-dose therapy was only given for two days around the surgery, he could likely be returned safely to his maintenance prednisone dose without sequelae.
Managing Steroid Cessation
Tapering of corticosteroid doses after short therapeutic courses at relatively low doses becomes an individualized decision based on the patient, his or her medical history, and the clinical condition under treatment. For some diseases such as asthma, limited documentation is available that steroids can be stopped quickly if appropriate adjuvant therapy is provided (inhaled bronchodilators).1
For other conditions, comparative research is unavailable. Tapering practices vary considerably between prescribers and depending on the length of therapy, the clinical condition being treated, and the patient's clinical status. As cost containment forces reassessment of many clinical practices that have been taken for granted, steroid tapering is an area ripe for scrutiny.
L. Michael Posey
Academics Editor
CC: Postsurgical care following colostomy.
HPI: JC, a 72-year-old man, was admitted to the subacute care unit for rehabilitation and observation after having a colostomy following daiscovery of a large abdominal mass on CT scan five days ago. Sigmoid colon was resected and terminus diverted to colostomy. Patient, who had been receiving prednisone 7.5 mg/day for COPD, received methylprednisolone 60 mg i.v. q 12 h for surgical stress prophylaxis for two days. In the subacute care unit, the goal is to taper from the high-dose steroid therapy back to his regular COPD dose before transfer to a nursing home.
PMH: Mild dementia requiring nursing home care. Smoked two packs of cigarettes per day until onset of COPD at age 67. History of peptic ulcer disease.
PR: Current medications include one multivitamin daily; acetaminophen 650 mg and codeine 30 mg q 4 h pain; heparin 5,000 units s.c. b.i.d.; prednisone 80 mg today, decrease by 10 mg/day until 20 mg/day, then 7.5 mg/day; ipratropium inhaler 4 puffs q.i.d.; and albuterol inhaler p.r.n.
SH: Widower; resident of nursing home.
ROS: Not contributory.
PE: Poor peripheral pulses noted.
Other: None.
Abbreviations used: CC = chief complaint, HPI = history of present illness, PMH = past medical history, PR = pharmacist review, SH = social history, ROS = review of systems, PE = physical examination, Labs = laboratory values; COPD = chronic obstructive pulmonary disease.
1. O'Driscoll BR, Kalra S, Wilson M, Pickering CAC, Carroll KB, Woodcock AA. Double-blind trial of steroid tapering in acute asthma. Lancet 1993; 341: 324-7.
2. American Thoracic Society. Chapter 3: pharmacologic therapy. In: Standards for the diagnosis and care of patients with chronic obstructive pulmonary disease (COPD) and asthma. Official statement of the ATS Board of Directors, 1986: 231-4.
3. USP DI. Drug information for the health care professional. Rockville, MD: United States Pharmacopeial Convention, 1996.