Steroid Stress Dosing and Weaning Clinical Pathway – Weaning

Steroid Stress Dosing and Weaning Clinical Pathway

Indications and Dosing for Weaning Below Physiologic Steroid Doses to Off

  • For children who received supraphysiologic doses of steroids for an underlying illness for > 4 wks, weaning to physiologic dosing is based on the control of the underlying disease.
  • Monitor for signs and symptoms of disease activity and adrenal insufficiency.
  • Recurrence of signs and symptoms of underlying disease may need an increase in steroid dose based on the primary team’s recommendations.
  • The goal of weaning below physiologic dosing levels is to avoid symptoms due to HPA suppression.
  • Physiologic dose of hydrocortisone: 8-10 mg/m2/day divided twice daily (a.m. and dinner time).
  • Weaning recommendations below physiologic:
    • Decrease hydrocortisone by 2 mg/m2/day weekly with a goal of stopping physiologic replacement within approximately 1 month.

Specific instructions for children who require stress dosing during weaning:

  • Children receiving less than 30 mg/m2/day of hydrocortisone or its equivalent will require additional stress dose steroids according to their stress dose regimen.
  • Once the stress has resolved, may resume weaning plan prior to the stress.

Physiologic Steroid Dosing Regimen Recommendations

  • Steroid doses should be timed as indicated below.
  • Avoid bedtime doses as this will suppress overnight rise in ACTH and could delay recovery of the HPA axis.
  • For primary adrenal insufficency can consider administering hydrocortisone 2.7-4 mg/m2/dose three times daily.
Chronic GC Therapy with Prednisone/Prednisolone/Methylprednisolone
  • Decrease prednisone/prednisolone to physiologic dose of 2 mg/m2/dose once daily given at 08:00
  • or
  • Convert to physiologic hydrocortisone 5 mg/m2/dose IV or PO twice daily given at 08:00 and 14:00
Chronic GC Therapy with Dexamethasone Convert to physiologic hydrocortisone
5 mg/m2/dose IV or PO twice daily given at 08:00 and 14:00
Chronic GC Therapy with Hydrocortisone
  • Decrease hydrocortisone to physiologic dose of 5 mg/m2/dose IV or PO twice daily given at 08:00 and 14:00
  • Weaning below physiologic dosing may be completed with IV, tablets rounded to the nearest 1.25 mg increment or oral suspension for inpatients.

Weaning Below Physiologic Steroid Dosing for Patients on Chronic GC Therapy > 4 wks

Chronic GC Therapy Duration Prednisone/Prednisolone/Methylprednisolone Wean Steps Hydrocortisone Wean Steps Duration of Each Step
< 4 wks No wean: discontinue prednisone No wean: discontinue hydrocortisone N/A
≥ 4 wks
  • Step 1
    Prednisone 2 mg/m2/dose once daily
  • Step 2
    Prednisone 1.5 mg/m2/dose once daily
  • Step 3
    Prednisone 1 mg/m2/dose once daily
    Discontinue prednisone
  • Step 4
    Discontinue prednisone
  • Step 1
    Hydrocortisone 5 mg/m2/dose twice daily
  • Step 2
    Hydrocortisone 4 mg/m2/dose twice daily
  • Step 3
    Hydrocortisone 3 mg/m2/dose twice daily
  • Step 4
    Discontinue hydrocortisone
GC therapy ≥ 4 wks-3 mos
4 days
GC therapy > 3 mos
7 days