Withdrawal from glucocorticosteroid therapy: clinical practice recommendations

Abstract

ResumoObjetivo: Apresentar uma revisão atualizada e prática sobre como efetuar de forma segura a retirada da corticoterapia. Fontes dos dados:Revisão da literatura utilizando os bancos de dados MEDLINE e LILACS (1997)(1998)(1999)(2000)(2001)(2002)(2003)(2004)(2005)(2006)(2007), selecionando os artigos mais atuais e representativos do tema. Síntese dos dados:Três situações clínicas podem ocorrer durante a retirada da corticoterapia prolongada: insuficiência adrenal secundária à supressão do eixo hipotálamo-hipófise-adrenal, síndrome de retirada ou deprivação dos corticóides e reativação da doença de base. Embora não exista consenso sobre o melhor esquema para descontinuar a terapia prolongada com corticóides, existe concordância quanto ao fato desta retirada ser gradual. Este artigo atualiza o pediatra quanto ao reconhecimento desses problemas e fornece orientações para a suspensão do tratamento prolongado com corticóide. Uma breve revisão da farmacologia dos corticóides também é descrita. Conclusão:Não existe teste com bom valor preditivo para antecipar o risco de insuficiência adrenal nos pacientes que receberam terapia crônica com corticóide. São necessários estudos prospectivos para avaliar a real incidência desse problema e assim propor estratégias racionais para sua prevenção. No momento, a menos que a integridade do eixo hipotálamo-hipófise-adrenal esteja estabelecida por testes dinâmicos, recomenda-se a administração de corticóide em situações de estresse nos pacientes que fizeram uso de corticoterapia crônica e/ou em doses elevadas.J Pediatr (Rio J). 2008;84(3):192-202: Insuficiência adrenal; síndrome de Cushing; síndrome de retirada dos corticóides; corticóides. AbstractObjective: To present an up-to-date and practical review of how to safely withdraw glucocorticosteroid therapy.Sources: A review of the published literature identified by searching the MEDLINE and LILACS databases (1997)(1998)(1999)(2000)(2001)(2002)(2003)(2004)(2005)(2006)(2007), selecting the most representative articles on the subject. Summary of the findings:Three clinical situations may occur during glucocorticoid withdrawal: adrenal insufficiency secondary to negative feedback on the hypothalamic-pituitary adrenal (HPA) axis, steroid withdrawal syndrome and relapse of the disease for which the glucocorticoids were prescribed. Although there is no consensus on how to best discontinue prolonged glucocorticosteroid therapy, there is agreement that this withdrawal should be gradual. This article updates pediatricians on how to recognize these problems and provides recommendations on how to safely suspend glucocorticosteroid therapy. A brief review of the pharmacology of glucocorticoids is also presented. Conclusion:There is no good predictive test for predicting the risk of adrenal insufficiency in patients who have been on corticosteroid therapy chronically. There is a need for prospective studies to assess the true incidence of this problem and to propose rational strategies for preventing it. The current recommendation is that patie...

Protective Effect of Phosphatidylcholine on Lipopolysaccharide-Induced Acute Inflammation in Multiple Organ Injury

“…Further, in clinical aspect, it is a cause of death with extremely high mortality rates in patients undergoing major surgery [28]. Although glucocorticosteroids remain the most effective therapy for inflammatory disorders, the side effects limit their clinical usefulness [29]. High-dose of corticosteroids to treat sepsis has been one of controversial clinical issues [30], and administration of high-dose corticosteroids does not benefit to treat patients with early and severe sepsis [31,32].…”

Comparison of steroid pulse therapy and conventional oral steroid therapy as initial treatment for autoimmune pancreatitis

“…Bile duct stenosis in the distal third part was significantly improved after 2 weeks in each group Although oral prednisolone was commenced, it had had no effect on the biliary stenosis (left). Two courses of steroid pulse therapy ameliorated the stenosis dramatically (right) (Case 10; reference [31]) secondary adrenal insufficiency due to hypothalamicpituitary-adrenal suppression [21][22][23]. Diagnostic treatment with an oral steroid may cause an undesirable effect when surgical resection is required.…”

“…Moreover, Korean investigators have reported the usefulness of a 2 weeks' trial of oral steroids in differentiating AIP from malignancy, with continuing administration if AIP is diagnosed [20]. However, it has not yet been established whether or not withdrawal of steroids in reconsidering malignancy presents a risk of postoperative adrenal insufficiency [21][22][23]. Therefore, it is desirable to have an alternative to the discontinuation of steroid administration immediately after surgery.…”

Outcome of a glucocorticoid discontinuation regimen in patients with inactive systemic sclerosis

“…To minimize the risk of onset of symptoms related to GC deprivation [27], a 6-month tapering (reduction of 10 % of the dose each week) regimen was planned. When an alternate daily 5-2.5 mg dosage of prednisone was reached, it was maintained for 3 weeks to minimize the risk of deprivation syndrome consequent to subphysiological GC dosages [28]. Patients with any complaints were examined within 1 week; others were re-examined 6 months after enrollment (T6).…”