Managing glucocorticoid dependence
The physical and psychological effects of glucocorticoid withdrawal can
make it difficult for patients to reduce the dose of their
glucocorticoids. In case studies 2 and 3 this is illustrated by patients
maintaining themselves on higher doses of glucocorticoids than those
prescribed by their physicians. When discussing glucocorticoid tapering,
patients should be counselled about the possibility of withdrawal
symptoms. If these occur at supraphysiological doses of glucocorticoids,
they can be managed by symptomatic treatments (e.g. non-steroidal
anti-inflammatories for aches and pains) and by slowing the rate of
glucocorticoid taper. If the symptoms are poorly tolerated, the dose of
glucocorticoids can be increased to the lowest dose at which they are
controlled and treatment tapered very slowly. If symptoms occur at or
below physiological glucocorticoid doses, adrenal insufficiency must be
excluded as described above. With time and a very slow treatment taper,
glucocorticoid dependence may resolve. Where patients are unable to stop
glucocorticoid therapy they should be maintained on the lowest possible
dose of treatment. Some endocrinologists recommend switching from
prednisolone to hydrocortisone if long term treatment is required
because hydrocortisone appears to be associated with a lower risk of
fractures [37].