What is the recommended minimum interval between repeat systemic corticosteroid courses in children?

Minimum Interval Between Repeat Systemic Corticosteroid Courses in Children

For short courses of systemic corticosteroids lasting less than 1-2 weeks, there is no mandatory waiting period between courses, and repeat dosing can be given as clinically indicated 1.

Key Principles for Repeat Dosing

Short-Course Therapy (≤7-10 days)

• No taper required for courses lasting 7-10 days or less 1, 2
• No mandatory waiting period between courses when treating acute conditions like asthma exacerbations 1
• Short courses (less than 2 weeks) are very unlikely to cause long-term side effects or significant HPA axis suppression 3
• The typical dose is 1-2 mg/kg/day (maximum 60 mg/day) for 3-10 days 1, 2

Practical Approach to Repeat Courses

For asthma exacerbations:

• Repeat courses can be given immediately as needed for subsequent exacerbations 1
• Each course should be 3-10 days at 1-2 mg/kg/day (max 60 mg/day) 1
• No specific interval is required between courses 1

For other acute conditions:

• Repeat dosing is acceptable when clinically indicated 3
• Consider the cumulative steroid exposure over time rather than focusing on a rigid interval 3

When to Exercise Caution

Prolonged or Frequent Use

• Courses exceeding 2 weeks warrant specialist referral and a formal weaning plan to prevent adrenal suppression 3
• For chronic conditions requiring repeated courses, consider steroid-sparing agents rather than indefinite repeat dosing 1
• HPA axis suppression becomes a concern with regimens >2-3 weeks at doses >7.5 mg/day 2

Monitoring Considerations

• Track cumulative steroid exposure across multiple courses 3
• Monitor for behavioral changes, growth velocity, and weight gain with frequent repeat courses 2, 4
• Consider calcium and vitamin D supplementation if multiple courses are anticipated 2

Special Situations

Nephrotic Syndrome

• For frequent relapses, switch to alternate-day maintenance dosing (40 mg/m² or 1.5 mg/kg on alternate days) rather than repeated short courses 1
• Consider corticosteroid-sparing agents if relapses occur frequently despite optimal steroid management 1

Intramuscular Preparations

• Triamcinolone acetonide should never be used more often than every 2 months due to unusually strong HPA axis suppression 5

Bottom Line Algorithm

1. For courses ≤7-10 days: Give repeat courses as clinically needed without mandatory waiting periods 1, 3
2. For courses >2 weeks: Refer to specialist and implement tapering plan 3
3. If requiring frequent repeat courses: Consider underlying disease control and steroid-sparing alternatives 1
4. Always use morning dosing to minimize HPA axis suppression 2, 4