Corticosteroids — chronic use, withdrawal, stress dose

What chronic steroids do to a body, when to taper, when to stress-dose.

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◆Equivalent doses (rough)

•Hydrocortisone 20 mg = prednisone 5 mg = methylprednisolone 4 mg = dexamethasone 0.75 mg
•Hydrocortisone has the most mineralocorticoid effect; dexamethasone has the least

•Iatrogenic Cushing syndrome: central obesity, moon facies, striae, buffalo hump
•Osteoporosis: give Ca + vit D, consider bisphosphonate if >5 mg prednisone × 3+ months
•Hyperglycemia / new-onset DM
•HTN, fluid retention
•Cataracts, glaucoma
•Avascular necrosis (esp femoral head)
•Mood changes: insomnia, mania, psychosis
•Skin: thinning, easy bruising, poor wound healing
•Infection susceptibility (bacterial, fungal, reactivated TB)
•PUD risk (esp with NSAIDs)
•Adrenal suppression with prolonged use → cannot stop abruptly

•Suppression occurs after ~3 weeks of >20 mg/day prednisone (or equivalent)
•TAPER over weeks-months; abrupt stop → adrenal crisis (hypotension, hyponatremia, hyperkalemia, hypoglycemia)
•After taper, may need stress-dose steroids for surgery/illness × 6–12 months

•Minor surgery / mild illness: continue usual dose or double × 24 hr
•Moderate surgery: hydrocortisone 50 mg IV pre-op, then taper over 1–2 days
•Major surgery / critical illness: hydrocortisone 100 mg IV q8h × 24–48 hr then taper
•Septic shock with relative adrenal insufficiency: hydrocortisone 200 mg/day

•Asthma exacerbation: short course (5 days) prednisone — no taper needed
•Giant cell arteritis (temporal): high-dose prednisone START before biopsy (vision-saving)
•Bell's palsy: prednisone within 72 hr improves outcomes
•Pneumocystis pneumonia: add steroids if PaO2 < 70 or A-a gradient ≥ 35
•Severe alcoholic hepatitis (MDF > 32): prednisolone reduces 28-day mortality

◆Chronic prednisone > 5 mg × 3 mo → check DEXA + start Ca/vit D + consider bisphosphonate
◆Never stop chronic high-dose steroids abruptly → adrenal crisis
◆Stress dose: triple usual dose for sick day; hydrocortisone IV for major stress
◆Steroid + NSAID = ↑ PUD risk — add PPI
◆Latent TB on chronic steroids → treat to prevent reactivation

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