Weaning Hydrocortisone in Infants with Bronchopulmonary Dysplasia
Taper hydrocortisone gradually over 3-10 days by reducing the dose by 10-20% every other day based on clinical response, monitoring closely for adrenal insufficiency and respiratory deterioration during the wean. 1
Specific Tapering Protocol
The most practical approach based on available evidence involves:
- Initial dose reduction: After completing the therapeutic course (typically 1 mg/kg/day divided into two doses), begin tapering by decreasing the dose by 10-20% every other day 1
- Duration of taper: The taper should extend over 3-10 days depending on the total duration of therapy and clinical stability 1
- Standard regimen example: If using 0.5 mg/kg every 12 hours, taper to 0.25 mg/kg every 12 hours for the final 3 days before discontinuation 2
Critical Monitoring During Weaning
Respiratory status: Watch for increased oxygen requirements, increased work of breathing, or need for escalation of ventilatory support, as these may indicate premature weaning 2
Adrenal function: Monitor for signs of adrenal insufficiency including hypotension, hypoglycemia, hyponatremia, and hyperkalemia, particularly if hydrocortisone was used for >7-10 days 2
Blood pressure and glucose: Check blood pressure regularly during the taper, as hypertension is a known complication that may persist or worsen during weaning 2, 3
Evidence-Based Rationale
The tapering approach is necessary because:
- HPA axis suppression: Prolonged corticosteroid use can suppress the hypothalamic-pituitary-adrenal axis, requiring gradual withdrawal to allow recovery 2
- Rebound inflammation: Abrupt discontinuation may lead to rebound pulmonary inflammation and respiratory deterioration in infants with BPD 2
- Safety profile: Hydrocortisone has demonstrated a more favorable neurodevelopmental safety profile compared to dexamethasone, with no adverse effects on neurodevelopmental outcomes at 18-22 months 2
Clinical Decision Points
If respiratory status worsens during taper: Slow the taper rate or temporarily increase the dose back to the previous level, then attempt a more gradual reduction 1
If signs of adrenal insufficiency appear: Consider stress-dose hydrocortisone coverage (2-3 times maintenance) during acute illness or procedures, and extend the taper duration 2
Minimum effective duration: Most studies used 10-12 day courses with 3-day tapers, suggesting this represents a reasonable minimum treatment duration before initiating the wean 2, 4
Important Caveats
Avoid abrupt discontinuation: Never stop hydrocortisone suddenly after more than 7 days of therapy, as this significantly increases the risk of adrenal crisis 2
Timing considerations: If the infant was started on hydrocortisone in the first 2 weeks of life for BPD prevention, the standard 10-12 day course with 3-day taper is appropriate 2, 4. For later "rescue" therapy (after 3 weeks), the observational data suggests starting at 1 mg/kg twice daily and tapering by 10-20% every other day based on clinical response 1
Concomitant medications: Be aware that infants receiving indomethacin or ibuprofen for patent ductus arteriosus closure may have increased risk of gastrointestinal perforation when combined with early hydrocortisone, though this risk appears lower with hydrocortisone than dexamethasone 2