Steroid Stress Dosing and Weaning Clinical Pathway – Precautions

Steroid Stress Dosing and Weaning Clinical Pathway

Length of Stress Dose Precautions and HPA Axis Evaluation after Discontinuation of Steroids

  • Evaluation of the hypothalamic-pituitary-adrenal (HPA) axis with an AM cortisol level surrounding discontinuation of steroids is suggested for all children who receive chronic glucocorticoids ≥ 2 weeks.
  • For HPA axis evaluation, consult endocrinology or proceed with the following steps:
    • AM cortisol levels to diagnose adrenal insufficiency. Obtain AM cortisol at 08:00 at least 24 hours after discontinuation of steroids. May wait longer for children on prednisone/dexamethasone (7 days). It is not necessary to wait 4 weeks after discontinuation of steroids to assess HPA axis.
  • If steroid-induced adrenal suppression is demonstrated by either an AM cortisol or a low dose ACTH stimulation test, it is recommended that an AM cortisol be obtained every 3 months until the HPA axis recovers. Stress dose precautions are required until HPA axis recovery is confirmed.
  • In a study of oncology patients with one month of exposure to glucocorticoids, all patients had recovery of their hypothalamic-pituitary-adrenal (HPA) axis by 3 months; however, recent studies suggested that recovery of HPA axis after prolonged steroid therapy can be variable, and that morning cortisol levels are not an adequate surrogate marker for an appropriate stress response. In such cases, additional testing such as a low dose ACTH test can be considered.
AM Cortisol Level mcg/dL* Action
≤ 12
  • Refer to Endocrinology to discuss necessity of low dose ACTH (cosyntropin) stimulation test**
  • Continue Stress Dosing Precautions
> 12
  • HPA axis is intact; no ACTH stimulation test required
  • Stress dosing precautions not indicated

* The AM cortisol cut-off may vary according to the cortisol assay used. For CHOP, the AM cortisol value of 12 mcg/dL can be used to clear the individual from adrenal insufficiency.

** With low-dose ACTH (coSYNtropin) stimulation testing, the cortisol level should rise to 18 mcg/dL or higher to consider the axis recovered. Lower peak cortisol levels may indicate axis recovery depending upon institution-specific test methodologies and should be interpreted according to institution-specific cut-offs. The cut-off for the current CHOP cortisol assay after ACTH stimulation testing is 15.5 mcg/dL.