What is the recommended dosage tapering approach for managing exogenous Cushing's syndrome in patients on glucocorticoids, such as prednisone (Deltasone)?

Recommended Tapering Approach for Exogenous Cushing's Syndrome

For patients with exogenous Cushing's syndrome, gradual tapering of glucocorticoids is essential, with a recommended approach of reducing prednisolone by 5 mg every 1-2 weeks after the initial therapeutic phase to minimize adrenal insufficiency risk. 1, 2

Initial Assessment and Recognition

• Identify symptoms of iatrogenic Cushing's syndrome:
  • Bruising, thin skin, edema, weight gain
  • Hypertension, hyperglycemia
  • Central obesity, moon facies, striae

Tapering Protocol

For Patients on High-Dose Glucocorticoids (e.g., Prednisone/Prednisolone)

1. Initial Phase:

   • Maintain therapeutic dose until disease control is achieved
   • For most conditions, maintain high-dose therapy for at least 2-4 weeks 3

2. Tapering Phase:

   • Begin tapering only after disease control is achieved
   • Reduce prednisolone by 5 mg every 1-2 weeks 1
   • Continue tapering until reaching a maintenance dose of 10 mg/day or less 3
   • Complete total treatment duration of at least 4-6 months for most conditions 3

3. Final Phase:

   • Once at low dose (≤10 mg/day), slow the taper further
   • Consider morning dosing (before 9 am) to minimize HPA axis suppression 2
   • Continue until complete withdrawal if possible

Special Considerations

• For patients with prolonged therapy (>3 months):
  • More gradual tapering is required
  • Consider alternate-day therapy during later stages of tapering 2
  • Monitor for adrenal insufficiency symptoms more closely

Monitoring During Tapering

1. Clinical Monitoring:

   • Assess for signs of disease relapse
   • Watch for symptoms of adrenal insufficiency:
     • Fatigue, weakness, dizziness, nausea
     • Hypotension, hypoglycemia

2. Laboratory Monitoring:

   • Consider morning cortisol testing for patients on long-term therapy
   • For indeterminate results (AM cortisol >3 mg/dL and <15 mg/dL), consider ACTH stimulation testing 1

Management of Complications

Adrenal Insufficiency

• If symptoms of adrenal insufficiency develop:
  • Return to previous effective dose
  • Slow the tapering schedule
  • Consider stress-dose steroids during illness or stress 1

Steroid Withdrawal Syndrome

• May occur despite acceptable cortisol levels 4
• Symptoms mimic adrenal insufficiency but cortisol levels are adequate
• Management: Temporary increase in glucocorticoid dose with slower subsequent tapering

Stress Dosing Guidelines

• During periods of stress (illness, surgery, trauma):
  • Minor illness: Double the regular oral replacement dose for 48 hours 1
  • Surgery: Administer hydrocortisone 100 mg IV at start of surgery, followed by infusion of 200 mg/24h 1

Patient Education

• Provide clear written tapering schedule
• Educate about signs of adrenal insufficiency
• Instruct on stress dosing protocols
• Recommend medical alert identification for patients at risk of adrenal insufficiency

This tapering approach balances the need to minimize complications of glucocorticoid therapy while preventing adrenal insufficiency. The gradual reduction strategy (5 mg every 1-2 weeks) has been shown to be effective in preventing withdrawal symptoms while allowing recovery of the HPA axis.