Do NOT Stop Prednisolone Abruptly During Acute Gastroenteritis
A patient on chronic prednisolone 10 mg daily for years must continue the medication during an episode of loose motion and vomiting, as abrupt discontinuation risks life-threatening adrenal crisis. The patient requires stress-dose corticosteroid coverage during this acute illness, not cessation of therapy.
Critical Risk: Adrenal Insufficiency
- Patients taking more than 7.5 mg prednisolone daily for more than 3 weeks develop hypothalamic-pituitary-adrenal (HPA) axis suppression, making them unable to mount an appropriate cortisol response to physiologic stress 1
- Acute gastroenteritis with vomiting and diarrhea constitutes a significant physiologic stress that requires increased corticosteroid coverage to prevent adrenal crisis 1
- The risk of adrenal insufficiency cannot be excluded and remains difficult to predict in individual patients, but must be anticipated in anyone receiving chronic corticosteroid therapy 1
Recommended Management During Acute Illness
Increase the corticosteroid dose temporarily rather than stopping it:
- For patients on 10 mg prednisolone daily, increase to approximately 25 mg hydrocortisone twice daily (or equivalent prednisolone dose) for 3 days during the acute gastroenteritis episode 1
- If vomiting prevents oral intake, switch to intravenous hydrocortisone 25 mg twice daily until oral medications can be tolerated 1
- Never abruptly discontinue corticosteroids without tapering in patients on chronic therapy 1
Addressing the Vomiting Component
- If the patient cannot retain oral prednisolone due to severe vomiting, parenteral corticosteroid administration is essential to maintain adequate replacement 1
- The patient and their treatment team, including the general practitioner, should be consulted for guidance on managing this acute situation 1
- Adequate hydration and electrolyte monitoring are important during gastroenteritis, but do not replace the need for continued corticosteroid coverage 1
Common Pitfall to Avoid
The most dangerous error would be stopping prednisolone entirely during this acute illness. While systemic corticosteroids should generally be avoided for psoriasis management due to risk of disease flare upon withdrawal 1, 2, this patient has already been on chronic therapy for years. The immediate risk of adrenal crisis from abrupt cessation far outweighs concerns about psoriasis flare 1.
After Resolution of Acute Illness
- Resume the baseline 10 mg daily prednisolone dose once the gastroenteritis resolves and the patient can tolerate oral intake 1
- Consider working with dermatology to develop a long-term plan to taper off systemic corticosteroids, as they are not recommended for chronic psoriasis management 1
- Chronic corticosteroid use at this dose requires monitoring for complications including osteoporosis, hypertension, diabetes, and cardiovascular disease 1