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].