Should prednisone be stopped in a patient with normal ESR and CRP, on Aspirin and Plavix, with a history of vascular stenosis and JAK2-positive condition, managed with Hydrea?

From the Guidelines

Prednisone should not be abruptly stopped in this patient with JAK2-positive myeloproliferative neoplasm despite normal inflammatory markers. Instead, a gradual taper under hematology supervision is recommended. The patient's complex medical profile—including vascular stenosis and dual antiplatelet therapy with Aspirin and Plavix—requires careful management of their steroid therapy. Abrupt discontinuation of prednisone can trigger adrenal insufficiency if the patient has been on long-term therapy, potentially causing hypotension, electrolyte abnormalities, and fatigue. Additionally, steroids may be playing a role in managing the inflammatory component of their JAK2-positive condition alongside Hydrea (hydroxyurea) 1.

The taper schedule should typically reduce the dose by 2.5-5mg every 1-2 weeks depending on the current dose and duration of therapy. During the taper, the patient should be monitored for disease flare, signs of adrenal insufficiency, and vascular complications. Normal ESR and CRP values suggest good disease control but aren't sufficient reason alone to discontinue therapy in this complex case where steroids may serve multiple purposes beyond inflammation control.

Key considerations in managing this patient include:

• The risk of bleeding associated with dual antiplatelet therapy, as highlighted in the 2017 ESC focused update on dual antiplatelet therapy in coronary artery disease 1
• The importance of individualized assessment of ischemic and bleeding risk in patients on dual antiplatelet therapy, as emphasized in the 2016 ACC/AHA guideline focused update on duration of dual antiplatelet therapy in patients with coronary artery disease 1
• The role of antiplatelet therapy in patients with lower extremity peripheral artery disease, as discussed in the 2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS guideline for the management of lower extremity peripheral artery disease 1

Given the complexity of this patient's condition and the potential risks associated with abrupt discontinuation of prednisone, a gradual taper under close supervision is the most appropriate course of action.

From the FDA Drug Label

If after a reasonable period of time there is a lack of satisfactory clinical response, prednisone should be discontinued and the patient transferred to other appropriate therapy. The patient has normal ESR and CRP, and is being treated with Aspirin and Plavix for vascular stenosis, and Hydrea for a JAK2-positive condition.

• The patient's clinical status and response to treatment should be closely monitored.
• Since the patient has normal inflammatory markers (ESR and CRP), and is on other medications for their condition, the need for prednisone should be reassessed.
• Gradual withdrawal of prednisone is recommended if it is to be stopped, rather than abrupt discontinuation. Given the lack of direct information on when to stop prednisone in this specific scenario, a conservative approach would be to continue monitoring the patient's condition and adjust the treatment plan as needed 2.

From the Research

Patient Management

The patient in question has a complex medical history, including a left preitooccipital infarction, left subclavian artery stenosis, and a JAK2-positive condition, managed with Hydrea. They are currently on Aspirin and Plavix for antiplatelet therapy and prednisone.

Antiplatelet Therapy

• The use of Aspirin and Plavix is appropriate for preventing thrombotic events in patients with a history of vascular stenosis and high-risk thrombocytosis 3, 4.
• Studies have shown that the combination of Aspirin and Plavix provides superior antithrombotic protection in coronary, cerebral, or peripheral arterial disease without an inordinate increase in bleeding complications 4.

Corticosteroid Therapy

• The patient is currently on prednisone, but there is no clear indication for its use in the management of their vascular stenosis or JAK2-positive condition.
• The decision to stop prednisone should be based on the patient's individual clinical circumstances and the presence of any inflammatory conditions that may require corticosteroid therapy.

Laboratory Results

• The patient's normal ESR and CRP levels suggest that there is no ongoing inflammatory process that would necessitate the use of prednisone 5.
• The patient's high hemoglobin and platelet counts are consistent with their JAK2-positive condition, and the use of Hydrea is appropriate for managing these laboratory abnormalities 6.

Next Steps

• Consultation with the patient's cardiologist, physician, and/or vascular surgeon is recommended to determine the best course of action regarding the use of prednisone and antiplatelet therapy 5.
• The patient's laboratory results and clinical circumstances should be closely monitored to ensure that their management plan is optimized and adjusted as necessary.