What is the recommended starting dose of prednisone (corticosteroid) for a patient with adrenal insufficiency due to abrupt discontinuation?

From the Guidelines

The recommended starting dose of prednisone for a patient with adrenal insufficiency due to abrupt discontinuation is typically 5-10 mg daily. This dose should be taken orally, usually as a single morning dose to mimic the natural cortisol rhythm, as suggested by the American Society of Clinical Oncology clinical practice guideline 1. For patients with severe symptoms, the dose may need to be temporarily higher and then tapered down to a maintenance dose.

The regimen should include instructions for stress dosing, where patients double or triple their dose during illness, surgery, or significant physical stress, as recommended in the management of immune-related adverse events in patients treated with immune checkpoint inhibitor therapy: ASCO guideline update 1. Patients should carry a steroid emergency card and wear medical alert identification. The dose works by replacing the cortisol that the adrenal glands are unable to produce, preventing symptoms such as fatigue, weakness, dizziness, nausea, and potentially life-threatening adrenal crisis.

Regular monitoring is essential to ensure the dose is adequate but not excessive, as both under-replacement and over-replacement can cause health problems, as noted in the guidelines for the management of glucocorticoids during the peri-operative period for patients with adrenal insufficiency 1. The goal is to use the lowest effective dose that relieves symptoms and allows normal functioning. Key considerations include:

• Starting with a dose of 5-10 mg daily, as indicated by the most recent guidelines 1
• Adjusting the dose based on symptoms and response to treatment
• Providing education on stress dosing and emergency procedures
• Ensuring regular monitoring to avoid under-replacement or over-replacement.

From the FDA Drug Label

The initial dosage of PredniSONE tablets may vary from 5 mg to 60 mg per day, depending on the specific disease entity being treated. If after long-term therapy the drug is to be stopped, it is recommended that it be withdrawn gradually rather than abruptly

The recommended starting dose of prednisone for a patient with adrenal insufficiency due to abrupt discontinuation is not explicitly stated in the drug label. However, it can be inferred that the dose should be individualized and based on the patient's response to treatment.

• The initial dosage may vary from 5 mg to 60 mg per day.
• It is recommended to withdraw the drug gradually rather than abruptly to avoid adrenal insufficiency. 2

From the Research

Adrenal Insufficiency and Prednisone

• Adrenal insufficiency is a condition where the adrenal glands do not produce adequate amounts of hormones, including cortisol and aldosterone 3, 4.
• The condition can be caused by abrupt discontinuation of glucocorticoid therapy, such as prednisone 5.
• Patients with adrenal insufficiency are at risk of adrenal crisis, which can be life-threatening if not treated promptly 3, 4.

Recommended Starting Dose of Prednisone

• There is no specific recommended starting dose of prednisone for patients with adrenal insufficiency due to abrupt discontinuation mentioned in the provided studies.
• However, the studies suggest that hydrocortisone is commonly used for glucocorticoid replacement therapy, with a typical dose of 15-25 mg/day in divided doses 3, 4.
• In cases of adrenal crisis, high-dose corticosteroids, such as hydrocortisone 200-300 mg/day, may be administered 6.
• It is essential to note that the dose and duration of prednisone therapy should be individualized and monitored closely to avoid over- or under-treatment 7.

Important Considerations

• Patients with adrenal insufficiency require careful and repeated education on the risks of adrenal crisis and the importance of dose adjustments during stressful situations 3, 4.
• The diagnosis and treatment of adrenal insufficiency can be challenging, and clinicians should have a high index of suspicion and be alert to important diagnostic clues 6.
• Further research is needed to improve glucocorticoid replacement therapy and reduce morbidity and mortality in patients with adrenal insufficiency 7.