What is the recommended approach to medication vacations for patients on long-term hydrocortisone (corticosteroid) therapy?

Management of Medication Vacations for Patients on Long-term Hydrocortisone Therapy

For patients on long-term hydrocortisone therapy, medication vacations are generally not recommended due to the risk of adrenal insufficiency and should only be considered in specific clinical scenarios with careful medical supervision and gradual tapering.

Understanding Adrenal Suppression Risk

Long-term hydrocortisone therapy can lead to hypothalamic-pituitary-adrenal (HPA) axis suppression, making abrupt discontinuation dangerous. The risk factors include:

• Duration of therapy: Use of hydrocortisone at doses ≥20 mg daily (equivalent to 5 mg prednisolone) for a month or more can lead to secondary adrenal insufficiency 1
• Dose relationship: Higher doses and longer duration of therapy increase risk of adrenal suppression
• Individual variability: Some patients develop adrenal suppression more readily than others

Clinical Scenarios Where Medication Adjustments May Be Considered

1. Elective Surgery

• For non-emergency surgery: Corticosteroids should be minimized or stopped preoperatively wherever possible to reduce risk of postoperative complications 2
• During surgery: Patients who have been on oral corticosteroids for more than 4 weeks prior to surgery should receive equivalent intravenous hydrocortisone while nil by mouth 2
• Perioperative management: Continue usual steroid regimen rather than administering "push-dose" steroids, as evidence for this practice is insufficient 2

2. Inflammatory Bowel Disease Management

• For patients with IBD having elective surgery, corticosteroids should be stopped if possible or brought to as low a dose as can be managed without disease deterioration 2
• Standardized steroid-taper protocols should be implemented in the postoperative period for patients who have had complete resection of active disease 2

3. Chronic Therapy Considerations

• For patients on rituximab cycles, it may be reasonable to postpone the next cycle if the clinical situation allows a delay 2
• For patients with IgG4-related disease, after disease control, tapering to maintenance treatment with low-dose corticosteroids (2.5-10 mg daily prednisone equivalent) may be considered 2

Contraindications to Medication Vacations

Medication vacations are absolutely contraindicated in:

1. Patients with known adrenal insufficiency
2. Patients with active disease requiring steroid therapy
3. During acute illness or physiological stress
4. COVID-19 infection: If a patient with rheumatic musculoskeletal disease receiving long-term glucocorticoid treatment develops COVID-19, this treatment should be continued 2

Implementation Protocol for Necessary Dose Reductions

When a medication adjustment is clinically indicated:

1. Assessment phase:

   • Check morning ACTH and cortisol levels (7-9 AM) to reflect normal diurnal peak 1
   • Consider ACTH stimulation test for indeterminate results 1

2. Tapering approach:

   • The tapering process may take months to years depending on duration of prior steroid use 1
   • Goal: Complete withdrawal or lowest effective dose that prevents both adrenal insufficiency and disease relapse
   • Monitor for symptoms of adrenal insufficiency and steroid withdrawal syndrome 1

3. Monitoring during taper:

   • Regular assessment of blood pressure, electrolytes, and glucose 1
   • Monthly assessments for the first 6 months, every 3 months for the next 6 months, and every 6 months thereafter 1

Special Considerations

• Pregnancy: Hydrocortisone requirements may increase during pregnancy, particularly in the third trimester 1
• Comorbidities: Patients with asthma and diabetes have higher risk of adrenal crisis 1
• Topical steroids: Even topical steroids can cause systemic effects with long-term use; therapy with any effective topical corticosteroid should be intermittent 1, 3
• Rebound phenomenon: Abrupt cessation can lead to rebound effects, including worsening of the underlying condition 4

Patient Education

Patients should be educated about:

• The importance of not stopping hydrocortisone abruptly
• Symptoms of adrenal insufficiency (fatigue, weakness, dizziness, nausea, hypotension)
• Need for stress dosing during illness or surgery
• Carrying a medical alert bracelet or card 1

Common Pitfalls to Avoid

1. Abrupt discontinuation: Can precipitate adrenal crisis
2. Inadequate stress dosing: During illness or surgery
3. Failure to recognize adrenal insufficiency: Symptoms may be nonspecific
4. Confusing medication holidays with nonadherence: Medication holidays should be planned and supervised 5

By following these guidelines, clinicians can safely manage patients on long-term hydrocortisone therapy while minimizing risks associated with medication adjustments when clinically necessary.