Can an 85-year-old female (F) experience adrenal insufficiency from a prednisone (corticosteroid) taper of 25 mg, 25, 20, 15, 10, 5, 5?

Risk of Adrenal Insufficiency with Prednisone Taper in an 85-Year-Old Female

Yes, an 85-year-old female can experience adrenal insufficiency from the described prednisone taper (25 mg, 25,20,15,10,5) as this rapid taper may not allow sufficient time for her hypothalamic-pituitary-adrenal axis to recover, especially given her advanced age. 1, 2

Mechanism of Adrenal Suppression

• Exogenous corticosteroids suppress adrenocortical activity, with recovery time varying based on:

  • Dose and duration of treatment
  • Age (elderly patients are more vulnerable)
  • Individual susceptibility

• Even a single dose of prednisone can produce adrenocortical suppression for 1¼ to 1½ days 2

• The rapid taper described (from 25 mg to 5 mg within a week) may not allow adequate time for the hypothalamic-pituitary-adrenal (HPA) axis to recover, particularly in an elderly patient 3

Risk Factors in This Patient

• Advanced age (85 years) - elderly patients have decreased physiologic reserve
• Rapid taper schedule - decreasing from 25 mg to 5 mg within a week
• Lack of gradual transition to alternate-day therapy
• Potential comorbidities common in elderly that may increase stress on the body

Signs and Symptoms to Monitor

• Fatigue, weakness, lethargy
• Nausea, vomiting, abdominal pain
• Hypotension, especially orthostatic
• Hypoglycemia
• Hyponatremia, hyperkalemia (in primary adrenal insufficiency)
• Confusion or altered mental status (particularly concerning in elderly)

Management Recommendations

1. Consider a more gradual taper:

   • Slower reduction once reaching physiological doses (below 10 mg prednisone)
   • Potentially extend time at 10 mg and 5 mg doses

2. Monitor for adrenal insufficiency:

   • Morning cortisol level if symptoms develop
   • ACTH stimulation test if indeterminate results

3. If adrenal insufficiency develops:

   • Return to previous effective dose
   • Implement a more gradual taper
   • Consider hydrocortisone replacement (15-20 mg daily in divided doses) 1, 3

4. Patient education:

   • Stress dosing instructions (double dose during minor illness)
   • Recognition of adrenal insufficiency symptoms
   • When to seek medical attention

Special Considerations for Elderly Patients

• Increased sensitivity to both glucocorticoid effects and withdrawal
• Higher risk of complications from adrenal insufficiency
• Concomitant medications may interact with glucocorticoid metabolism
• Comorbidities may mask or exacerbate symptoms of adrenal insufficiency

Common Pitfalls to Avoid

• Tapering too rapidly through physiologic doses (below 10 mg prednisone)
• Failing to recognize symptoms of adrenal insufficiency
• Not providing stress-dose instructions
• Assuming complete recovery of adrenal function immediately after completing taper

In conclusion, this elderly patient is at significant risk for adrenal insufficiency with the described taper schedule. A more gradual reduction, particularly when reaching physiologic doses, would be safer. Close monitoring for symptoms of adrenal insufficiency is essential, with a low threshold for intervention if symptoms develop.