Procedures for tapering steroids are empirical. Their success
is determined by the length and mode of therapy and by individual
patient responses. Patients treated with alternate day
therapy can be withdrawn more easily than those receiving daily
therapy, especially daily therapy with a long acting glucocorticoid
such as dexamethasone. In patients on long standing therapy,
a 25% reduction in the previous level of therapy is generally
recommended weekly. A patient with a body surface area of 1 m2 will
have a secretory rate of cortisol of about 9 mg/d, equivalent
to 20 mg/d of orally administered cortisone acetate. If
the patient has been on daily therapy equivalent to 100 mg of cortisone
acetate for many months, a tapering protocol over 8 to 10 weeks
may be needed. A protocol of 75% of the previous week’s
dose would thus be 75 mg/d for the first week, 56 mg/d
for the second, then 42, 31.5, 24, 18, 13.5, 10, 7.5, 5.5 mg/d,
then off treatment. A more practical regimen based on the sizes
of tablets available would be 75, 50, 37.5, 25, 17.5, 12.5, 10,
7.5, and 5 mg/d, typically divided into 3 doses. Most patients can
be tapered more rapidly, but all patients need to be followed closely.
If withdrawal is done with steroids other than cortisone or cortisol,
measurement of morning cortisol values can be a useful adjunct. Morning
cortisol values of 10 μg/dL or more indicate
that the dose can be reduced safely.