Priya Gagan, Laway Bashir A, Ayyagari Mythili, Gupta Milinda, Bhat Ganesh H K, Dutta Deep
Department of Endocrinology, Fortis Hospital, Mohali, Punjab, India.
Department of Endocrinology, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, Kashmir, India.
Indian J Endocrinol Metab. 2024 Jul-Aug;28(4):350-362. doi: 10.4103/ijem.ijem_410_23. Epub 2024 Aug 28.
Glucocorticoid (GC) therapy can ameliorate debilitating and life-threatening symptoms in several inflammatory/immunological disorders. However, it can also cause significant side effects, especially with higher doses and longer duration of use. Therefore, GCs should be used at the lowest effective dose for the shortest possible time to minimise adverse effects. GC therapy may cause suppression of the endogenous hypothalamic-pituitary-adrenal (HPA) axis and abrupt discontinuation predisposes patients to features of GC-induced adrenal insufficiency. The practice of tapering GC therapy allows for recovery of the HPA axis while minimising the risk of a disease flare-up or symptoms of AI. Moderate-to-high dose GC therapy may be tapered rapidly to near-physiological doses while watching for features of disease reactivation. Once close to the physiological dose, tapering is slower and at longer intervals to allow for recovery of the HPA axis. It is important to use short- or intermediate-acting GC preparations such as hydrocortisone or prednisolone in physiological doses, administered in the morning to mimic the endogenous cortisol rhythm. A general principle to follow is that HPA axis recovery takes longer if the period of suppression has been long. In such cases, tapering should be slower over a few months to even a year. In select cases at high risk of AI or if symptoms appear during tapering, the decision to further taper and discontinue steroids may be based on testing of HPA axis function using basal and/or stimulated serum cortisol. All patients on exogenous steroids should be advised about the need for an appropriate increase in GC doses during acute medical or surgical illness and should carry a steroid alert card to avoid adrenal crisis.
糖皮质激素（GC）疗法可改善多种炎症/免疫性疾病中使人衰弱且危及生命的症状。然而，它也会引起显著的副作用，尤其是在高剂量和较长使用期时。因此，应在最短时间内使用最低有效剂量的GC，以将不良反应降至最低。GC疗法可能会抑制内源性下丘脑-垂体-肾上腺（HPA）轴，突然停药会使患者易出现GC诱导的肾上腺功能不全的症状。逐渐减少GC疗法的用量可使HPA轴恢复，同时将疾病复发或肾上腺功能不全症状的风险降至最低。中高剂量的GC疗法可迅速减量至接近生理剂量，同时留意疾病重新激活的特征。一旦接近生理剂量，减量速度就会变慢，间隔时间变长，以便HPA轴恢复。重要的是使用生理剂量的短效或中效GC制剂，如氢化可的松或泼尼松龙，在早晨给药以模拟内源性皮质醇节律。遵循的一般原则是，如果抑制期较长，HPA轴恢复所需时间会更长。在这种情况下，应在几个月甚至一年的时间内更缓慢地减量。在肾上腺功能不全高风险的特定病例中，或者在减量过程中出现症状时，进一步减量和停用类固醇的决定可能基于使用基础和/或刺激后的血清皮质醇对HPA轴功能进行检测。所有接受外源性类固醇治疗的患者都应被告知在急性内科或外科疾病期间适当增加GC剂量的必要性，并应携带类固醇警示卡以避免肾上腺危象。
