The longer the duration of therapy the slower must be the withdrawal. For use of less than 1 week (e.g. in severe asthma), although there is some hypothalamic suppression, withdrawal can be safely accomplished in a few steps. After use for 2 weeks, if rapid withdrawal is desired, a 50% reduction in dose may be made each day; but if the patient has been treated for a longer period, reduction in dose is accompanied by the dual risk of a flare up of the disease and of iatrogenic hypoadrenalism; then withdrawal should be done very slowly, e.g. 2.5-5 mg prednisolone or equivalent at intervals of 3-7 days.
An alternative scheme is to try halving the dose weekly until 25 mg prednisolone or equivalent is reached, after which it may be reduced by about 1 mg every third to seventh day. Paediatric tablets (1 mg) can be useful during withdrawal.
But these schemes may yet be found too fast (giving rise to the occurrence of fatigue, 'dish-rag' syndrome, or relapse of disease) and the rate may need to be even as slow as prednisolone 1 mg per day (or equivalent) per mouth, particularly as the dose approaches the level of physiological requirement (equivalent of prednisolone 5-7.5 mg daily).
The long tetracosactride test (see later) or measurements of plasma corticotropin concentration may be used to assess recovery of adrenal responsiveness, but a positive result should not be taken to indicate full recovery of the patient's ability to respond to stressful situations; the latter is best shown by an adequate response to insulin-induced hypoglycaemia (which additionally tests the hypothalamic/pituitary capacity to respond).
Corticotropin should not be used to hasten recovery of the atrophied cortex since its effects cause further suppression of the hypothalamic-pituitary axis, on the recovery of which the patient's future depends. Complete recovery of normal hypothalamic/pituitary/adrenal function sufficient to cope with severe intercurrent illnesses or surgery is generally complete in 2 months but may take as long as 2 years.
There have been many reports of collapse, even coma, occurring within a few hours of omission of steroid therapy, e.g. due to patients' ignorance of the risk to which their physicians are exposing them or failing to have their tablets with them and other trivial causes; but it is not invariable. Patients must be instructed on the hazards of omitting therapy and, during intercurrent disease, i.m. preparations should be freely used. Anaesthesia and surgery in adrenocortical insufficency is discussed on page 676.
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