Corticosteroid Dosing

Question 1

Is there set guidelines for CS dosing?

Answer 1

There is no set guidelines

Question 2

What is the goal of CS dosing? What is considered in a dose?

Answer 2

Goal is to bring inflammation or immunologic reactions under control with the MED (minimal effective dose)

• Need to balance disease activity and toxicity
• Dose will depend on the specific situation and clinical experience

Question 3

Dosing regimen of initial dosing

Answer 3

OD or BID

Question 4

Dosing regime of maintenance dosing

Answer 4

OD

Question 5

What is the normal range of dosing for prednisone:

Answer 5

0.5-1 mg/kg/day

Question 6

CS’s duration recommendation?

Answer 6

CS’s have AE’s with chronic use, so it’s best to use for shortest amount of time if possible

Question 7

Can CS’s be discontinued automatically?

Answer 7

No

Corticosteroids may need to be tapered upon discontinuation if HPA-axis suppression is suspected

Question 8

When would tapering of a corticosteroid not be necessary?

Answer 8

If on a short-term CS for <3 weeks – taper may not be necessary

Question 9

How can one taper CS?

Answer 9

May ↓ daily dose by set amounts every few days / weeks
E.g. ↓ by 1mg to 2.5mg to 5mg prednisone q 3-7days
Decrease depends on starting point

Or may ↓ daily dose by a percentage. I.e. 5-10% per week

Question 10

What may happen when you reach 5 mg prednisone?

Answer 10

When reach 5mg prednisone – may see conversion to HC 20mg and then a further taper (equivalent potency –same dose) –> can then decrease the hydrocortisone

Question 11

If someone is on a divided dose therapy, what are the recommendations to going to OD dosing?

Answer 11

Divided dose < 2weeks: convert ASAP

Divided dose > 2 weeks: convert over a 2 week period

Question 12

What is the ultimate goal of tapering? What should be monitored?

Answer 12

Ultimate goal of tapering in all situations is to avoid rapid steroid withdrawal sx’s

As tapering occurs, monitor for flares/stress

Question 13

IS alternate day dosing (EOD) possible with CS’S. If so, why is it possible, what is the benefit, and which CS’s are used?

Answer 13

Due to their biological t½, CS’s can be dosed EOD

EOD will theoretically be less suppressive of HPA Axis. Minimize a/e on growth, chance of infections

Want to use a CS with a short-intermediate D of A to minimize accumulation which could negate EOD benefits

Question 14

What are some situations you may see EOD dosing being used?

Answer 14

Chronic administration necessary
Children requiring maintenance dosing

Question 15

How can one calculate EOD dosing?

Answer 15

Determine minimal effective daily dose
Taper current daily dose by 2.5 – 5mg /week until MED is achieved
E.g. 30, 25,20,15

The optimal EOD dose is 2.5 – 3x the MED
E.g. 15 mg x 3 = 45 mg

Alternate the new calculated dose with MED

Taper the MED dose by 5mg/week until removed
E.g. 45/15 45/10 45/0

Taper current dose by 5mg/week to the lowest dose that controls sx’s (achieve a new MED)
E.g. 45/0 40/0 35/0 30/0

Question 16

What is the goal of alternate day dosing?

Answer 16

Every other day dosing at the lowest effective dose

Question 17

Define stress dosing of corticosteroids. Whaqt does the dose depend on?

Answer 17

CS doses may have to be supplemented in some situations in someone on long-term CS’s.

Amount & duration of stress dose depends upon:
Pre-op dose of steroid taken by patient
Pre-op duration of steroid administration
Nature of the illness or surgery

Question 18

What are some stress-dosing examples?

Answer 18

Minor procedures (with local anesthesia): no extra supplementation

Moderate illness: HC 50mg po/IV bid- rapidly taper to maintenance dose (MD) as recover

Major surgery: HC 100mg IV pre-surgery, then 100mg q8h x 24h. Taper rapidly (by 50% daily) to MD

Question 19

What is steroid pulse therapy? Examples of conditions? Are the dosing regimens the same?

Answer 19

The administration of short term, high-dose, IV or PO steroids in various situations (i.e. juvenile RA, nephrotic syndrome) where rapid remission of serious conditions is desired

There are considerable variations in dosing regimens

Question 20

What are some examples of steroid pulse therapy?

Answer 20

Methylprednisolone 20/30mg/kg IV (max 1000mg) at intervals of every 24-48hrs; usually for 3-6 pulses
Acute MS relapse: 1250mg prednisone po x3-5d – equivalent to parenteral dosing

Question 21

What are some advantages of steroid pulse therapy?

Answer 21

More rapid control of condition

Help avoid AE’s by avoiding prolonged steroid therapy (cumulatively less toxic) – steroid sparing effects?!

Question 22

What are some disadvantages of steroid pulse therapy?

Answer 22

Certain adverse effects may be more likely and significant

Examples:
hypertension
Infection
Seizure
Psychosis