To Prevent Hypocortisolism and Development of Adrenal Insufficiency or Adrenal Crisis

• Assess patients at risk for adrenal insufficiency with screening tests (serum cortisol, plasma ACTH stimulation, etc.)

• If the patient requires discontinuation from chronic treatment with supraphysiologic doses of glucocorticoid, the following discontinuation protocol can be used4:

• Gradually taper the dose to approximately 20 mg of prednisone or equivalent per day, given in the morning, then

• Change glucocorticoid to every other day administration, in the morning

• Stop the glucocorticoid when the equivalent physiologic dose is reached (20 mg/ day of hydrocortisone or 5-7.5 mg/day of prednisone or equivalent)

• Understand that recovery of the HPA axis may take up to a year after glucocorticoid discontinuation during which the patient may require supplementation therapy during periods of physiologic stress

• Evaluate patients at risk for adrenal insufficiency as a result of treatment(s) of Cushing's syndrome and initiate glucocorticoid and mineralocorticoid replacement therapy as appropriate

• Avoid concurrent administration of drugs that can induce glucocorticoid metabolism

• Educate patients about:

• The need for replacement or supplemental glucocorticoid and mineralocorticoid therapy

• How to administer parenteral glucocorticoid if unable to immediately access medical care during an emergency

• Need to wear or carry medical identification regarding their condition (e.g., card, bracelet)

ACTH, adrenocorticotropic hormone or corticotropin; HPA, hypothalamic-pituitary-adrenal.

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