Treatment with glucocorticoids, or more popularly corticosteroids, is used in a wide range of situations in medicine and, therefore, it is important that we are familiar with these medications. They are drugs used for their potent anti-inflammatory effect and also, in some situations, immunosuppressive.
Situations such as rheumatological diseases (rheumatoid arthritis, vasculitis, systemic lupus erythematosus, polymyalgia rheumatica, among others); treatment of transplant patients; chronic lung diseases and several other diseases often use corticosteroids as a key treatment item.
Often, in prolonged treatments, corticosteroids can generate a series of side effects, in addition to inhibiting the production of natural corticosteroids by the body itself, due to inhibition of the hypothalamic-pituitary-adrenal axis.
With this, we must perform the famous “weaning” of the corticoid, after the use of high doses or after a more prolonged treatment, so that the axis can return to spontaneous production.
WHAT ARE THE INDICATIONS FOR CARRYING OUT / REMOVING THE CORTICOIDE?
Among these indications are:
. when the maximum desired effect of therapy has been obtained;
. when there is no effect expected after a therapeutic test;
. when major adverse effects, such as osteoporosis and hypertension, become severe or refractory to treatment
In addition, there are two complications in the use of corticosteroids that require immediate cessation of use, or rapid withdrawal:
. glucocorticoid-induced psychosis, unresponsive to antipsychotic medications;
. corneal ulcer induced by herpes virus.
If immediate cessation is not possible, the lowest necessary dose should be used, with medication withdrawal as soon as possible.
SUPPRESSION OF THE HYPOTHALAMOUS-HYPOPHYSIS-ADRENAL AXIS:
Administration of exogenous glucocorticoids may be able to suppress the hypothalamic-pituitary-adrenal axis. Thus, abrupt cessation of treatment with corticosteroids or with very fast weaning can lead to signs / symptoms related to adrenal insufficiency.
– How to identify patients with the suppressed axis?
The potency, dose and duration of the use of corticosteroids are important factors to predict the presence of suppression of the hypothalamic-pituitary-adrenal axis, although they are not absolute factors.
We should suspect axial suppression in any patient using glucocorticoids in association with the following situations:
. use of doses comparable with 20 mg of prednisone (or more) per day for more than three weeks or;
. use of nightly doses of at least 5 mg of prednisone or more for a few weeks or;
. any patient with “Cushingoide” appearance
– Who are the patients who probably do not have axial suppression?
. patients using any dose of glucocorticoid for less than 3 weeks or;
. patients being treated with an alternate dose of prednisone of less than 10 mg (or equivalent).
– Patients with intermediate / uncertain risk of axial suppression:
. those who use 10-20 mg of prednisone daily for more than three weeks;
. any patient using a dose of less than 10 mg of prednisone per day for more than a few weeks
If corticosteroid withdrawal is indicated in these patients at intermediate risk of axial suppression, gradual dose reduction is also indicated, that is, weaning.
ARE THERE OTHER WAYS OF GLUCOCORTICOID “DEPENDENCE”?
There are reports of other forms of glucocorticoid “dependence”, which would indicate weaning:
. psychological dependence on steroids;
. relapse of the disease for which the drug was prescribed;
. symptoms of adrenal insufficiency, despite normal function of the hypothalamic-pituitary-adrenal axis
Before starting to talk about this issue, it is important to make it very clear that there is a dearth of scientific evidence to strengthen any specific corticosteroid weaning regimen.
As mentioned earlier, a corticosteroid therapy of up to 3 weeks, even at a high dose, can be stopped suddenly without dose reduction (although most doctors do not do this in practice).
In patients on therapy for longer, it is recommended that some variables are also taken into account. Are they:
. age; fragility; comorbidities; risk of outbreak of the disease treated with corticosteroids; psychological factors and duration of medication use;
. stability of the disease in question to allow corticosteroid removal;
. long-term use without “pulse therapy”;
. remember that it is very rare to suppress the hypothalamic-pituitary-adrenal axis using low doses, such as prednisone 5 mg / day
PROPOSED WEANING SCHEMES:
The objective is a gradual reduction in order not to evolve with adrenal insufficiency in the withdrawal, in addition to avoiding any disease recurrence. Therefore, the proposed forms of weaning include reducing:
– 5 to 10 mg / day every one to two weeks from a dose used above 40 mg / day of prednisone (or equivalent);
– 5 mg / day every one to two weeks in doses of 20-40 mg / day of prednisone (or equivalent);
– 2.5 mg / day every two to three weeks in a prednisone dose of 10-20 mg / day (or equivalent);
– 1 mg / day every two to four weeks in doses of prednisone between 5-10 mg / day (or equivalent);
– 0.5 mg / day every two to four weeks in doses of prednisone from 5 mg / day. This can be achieved by alternating daily doses. For example, using 5 mg one day and 4 mg the other day.
It is common for some patients with rheumatological diseases to complain of recurrent base symptoms, such as arthralgia and myalgia. If the symptoms are not severe, it is advisable to wait a period of 7 to 10 days, using non-steroidal anti-inflammatory drugs.
If symptoms resolve, this suggests corticosteroid “withdrawal”. If there is no resolution, he speaks in favor of real recurrence of the disease itself, being advised to increase the dose of corticoid by 10 to 15%, maintaining it for a period of two to four weeks, and to continue weaning again later (in case of symptoms disappear).
If this increase in dose is not sufficient to control symptoms, it is advisable to double the dose of prednisone that was present at the time of recurrence of the clinical condition. In life-threatening outbreaks, the return of the original highest dose of glucocorticoid is the most appropriate to do.
ALTERNATE DAY SCHEME:
There is no proof of the advantage of this type of regime. However, it is performed as follows: whole dose administered every other day. After reaching a daily dose of 20-30 mg, the dose can be reduced by 5 mg / day every 1-2 weeks until reaching 10 mg / day.
When this dose is reached, it is reduced by 2.5 mg / day every 1-2 weeks. In general, this regimen is effective in most rheumatological diseases, but patients with rheumatoid arthritis do not usually tolerate administration on alternate days.
There are several other described forms of withdrawal / weaning from corticosteroids. However, those cited in this article are the most used and most grounded today. Therefore, just choose one of the ways (according to each person’s practice) and start weaning your patient on corticosteroids, if indicated.