From the Guidelines
It is generally okay to give steroids again for a new issue if a patient has been off steroids for 10 days after a 12-day course, as this timing allows the hypothalamic-pituitary-adrenal (HPA) axis to recover in most cases. The British Society of Gastroenterology consensus guidelines on the management of inflammatory bowel disease in adults suggest that patients receiving prolonged courses of corticosteroids are at risk of adrenal suppression and should have a tapering course if stopping 1. However, in this case, the 10-day gap between steroid courses reduces the risk of adrenal suppression, which typically becomes a concern with courses longer than 2-3 weeks.
- Common steroid options include prednisone (starting at 20-40mg daily), methylprednisolone, or dexamethasone, with the specific choice depending on the new medical issue being treated.
- The dose and duration should be tailored to the current condition, using the lowest effective dose for the shortest necessary period.
- Since the patient is not diabetic, there's less concern about significant glucose elevation, though blood sugar monitoring may still be prudent during treatment.
- For repeated or frequent steroid courses, consider steroid-sparing alternatives when possible to minimize cumulative side effects.
- It is essential to note that the definition of severe exacerbations and the use of systemic corticosteroids may vary depending on the clinical context and guidelines, as discussed in the American Thoracic Society/European Respiratory Society statement on asthma control and exacerbations 1.
From the FDA Drug Label
Recovery time for normal HPA activity is variable depending upon the dose and duration of treatment. Corticosteroids can produce reversible hypothalamic-pituitary adrenal (HPA) axis suppression with the potential for corticosteroid insufficiency after withdrawal of treatment. Adrenocortical insufficiency may result from too rapid withdrawal of corticosteroids and may be minimized by gradual reduction of dosage This type of relative insufficiency may persist for up to 12 months after discontinuation of therapy; therefore, in any situation of stress occurring during that period, hormone therapy should be reinstituted.
The patient has been off steroids for 10 days after being on them for 12 days. HPA axis suppression is a concern, and the patient may still be experiencing adrenocortical insufficiency.
- The recovery time for normal HPA activity is variable and depends on the dose and duration of treatment.
- Corticosteroid insufficiency can occur after withdrawal of treatment, and adrenocortical insufficiency may persist for up to 12 months after discontinuation.
- In situations of stress, hormone therapy should be reinstituted. Given the patient's recent history of steroid use, it is not clear if it is okay to give steroids again for a new issue without risking further HPA axis suppression or adrenocortical insufficiency. It is recommended to exercise caution and consider the potential risks and benefits of reinstituting steroid therapy. 2 2
From the Research
Adrenal Insufficiency and Steroid Use
- The patient has been off steroids for 10 days after taking them for 12 days, and the question is whether it's okay to give steroids again for a new issue.
- According to 3, secondary adrenal insufficiency (AI) occurs when exogenous corticosteroid therapy is administered at supraphysiologic dosages for ≥ 1 month, which is not the case here.
- However, 4 states that glucocorticoid-induced adrenal insufficiency can occur even with shorter durations of steroid use, and diagnosis is often based on clinical suspicion rather than routine testing.
Risk of Adrenal Insufficiency
- 5 found that 43% of patients on long-term systemic glucocorticoid treatment demonstrated evidence of possible tertiary adrenal insufficiency, and steroid dose at the time of testing was a significant predictive risk factor.
- The study also found that patients who remained on prednisolone were more likely to recover than those switched to hydrocortisone.
- 6 emphasizes the importance of identifying and treating adrenal insufficiency to prevent adrenal crisis and death.
Guidance for Steroid Use
- 7 summarizes the basic pharmacology, complications, and practice delivery issues regarding steroids, highlighting the need for practitioners to be aware of potential side effects and clinical implications.
- Given the patient's relatively short duration of steroid use and time off steroids, it's possible to consider restarting steroids for a new issue, but caution and monitoring for adrenal insufficiency are necessary, as suggested by 4 and 6.