Safely withdrawing patients from chronic glucocorticoid therapy

The withdrawal of patients from chronic glucocorticoid therapy can be a vexing problem. Symptoms of adrenal insufficiency are often subtle, and the potential complications of too-rapid withdrawal are catastrophic. The increased use of inhaled, intranasal and "superpotent" topical preparations will place more and more patients at risk for hypocortisolism. This article presents a safe, practical algorithmic approach to steroid withdrawal that can be determined in the physician's office. The recognition that patients are on maintenance steroid therapy should prompt a constant reevaluation of the need for such therapy, including consideration of an alternate-day drug regimen. The keys to success in withdrawing patients from steroid therapy include improving patient awareness of the signs and symptoms of steroid withdrawal, close follow-up and correct performance of the cosyntropin challenge, which is safe, practical and reliable. During the steroid withdrawal period, it is extremely important that the patient be proactive in identifying subtle symptoms and bringing them to the physician's attention.