Should we continue or stop the 1.25 mg alternate day prednisolone regimen in a patient who has tapered from 16 mg tds of methylprednisolone over 3 months with current 8 am cortisol levels of 7.8?

Steroid Taper Management: HPA Axis Recovery Assessment

Direct Recommendation

Continue the 1.25 mg alternate day prednisolone for at least another 1-2 months before attempting discontinuation, as the current 8 am cortisol of 7.8 mcg/dL (after 48 hours off prednisolone) indicates incomplete HPA axis recovery and places the patient at risk for adrenal crisis.

Clinical Reasoning

Current HPA Axis Status

Your patient's morning cortisol of 7.8 mcg/dL after 48 hours without prednisolone is borderline insufficient and does not confirm adequate adrenal reserve:

• Normal 8 am cortisol should be >10 mcg/dL, with values >18-20 mcg/dL indicating robust HPA axis function 1
• The cortisol level has shown minimal improvement from 7.5 to 7.8 mcg/dL over one month, suggesting slow recovery 1
• Hypothalamic-pituitary-adrenal axis suppression should be anticipated in any patient receiving more than 7.5 mg prednisolone equivalent daily for more than 3 weeks 1

Risk Assessment for Stopping Steroids

Your patient has significant risk factors for adrenal insufficiency:

• Started on 48 mg/day methylprednisolone equivalent (16 mg TDS = approximately 60 mg prednisolone daily) 2, 3
• Duration of 3+ months of supraphysiologic dosing creates prolonged HPA suppression 1
• Current cortisol levels indicate the adrenal glands are not yet producing adequate endogenous cortisol 1
• Abrupt discontinuation risks adrenal crisis, which can be life-threatening with mortality implications 1, 4

Recommended Management Algorithm

Step 1: Continue Current Dose

• Maintain 1.25 mg prednisolone alternate day for another 4-8 weeks 1, 4
• This provides minimal exogenous support while allowing continued HPA axis recovery 1

Step 2: Repeat Testing

• Recheck 8 am cortisol after 48 hours off prednisolone in 1-2 months 1
• Target cortisol >10 mcg/dL minimum, ideally >15 mcg/dL before considering discontinuation 1
• If cortisol remains <10 mcg/dL, consider ACTH stimulation test to assess adrenal reserve 1

Step 3: Discontinuation Criteria

• Only stop prednisolone when 8 am cortisol is consistently >10-15 mcg/dL 1
• Even after stopping, the patient requires stress-dose steroid education for intercurrent illness 1
• Risk of adrenal insufficiency may persist for 6-12 months after complete withdrawal 1

Critical Safety Considerations

Patient Education Requirements:

• Teach stress-dosing protocols: increase to 10-20 mg hydrocortisone equivalent during fever, infection, surgery, or trauma 1
• Provide emergency injectable hydrocortisone or instructions to seek immediate medical care 1
• Consider medical alert bracelet indicating adrenal insufficiency risk 1
• Inform all treating physicians about prolonged steroid use and HPA suppression risk 1

Warning Signs of Adrenal Crisis:

• Severe fatigue, weakness, hypotension, nausea/vomiting, confusion 1
• These symptoms during intercurrent illness require immediate stress-dose steroids (hydrocortisone 50-100 mg IV Q6-8 hours initially) 1

Why Not Stop Now?

Stopping at cortisol 7.8 mcg/dL is premature and dangerous:

• This level indicates inadequate basal cortisol production 1
• The patient cannot mount appropriate stress response to illness, surgery, or trauma 1
• Adrenal crisis has significant morbidity and mortality - this is your primary concern 1
• The minimal dose of 1.25 mg alternate day has negligible adverse effects compared to crisis risk 1, 4

Monitoring During Continuation Phase

• Clinical assessment for cushingoid features (should be minimal at this dose) 1
• Monitor for signs of adrenal insufficiency: fatigue, orthostatic hypotension, weight loss 1
• Blood pressure and glucose monitoring (though risk is low at 1.25 mg alternate day) 1
• Bone density consideration if prolonged therapy anticipated, though current dose is near-physiologic 1

The conservative approach of continuing low-dose alternate-day therapy prioritizes patient safety and mortality prevention over rapid steroid discontinuation 1, 4.