Glucocorticoid Tapering in Exogenous Cushing's Syndrome

Introduction to Tapering

The American College of Clinical Oncology recommends considering standard-dose ACTH stimulation testing for indeterminate results (AM cortisol >3 mg/dL and <15 mg/dL) 1
For patients recovering from exogenous Cushing's syndrome, reduce maintenance dosing when symptoms of iatrogenic Cushing's syndrome appear (bruising, thin skin, edema, weight gain, hypertension, hyperglycemia) 1

Patients who respond to glucocorticoid treatment should receive glucocorticoids for ≥6 months total duration 2
Tapering should be done gradually, rather than abruptly, to minimize secondary adrenocortical insufficiency, although the exact duration is not specified in the provided references

If symptoms of adrenal insufficiency develop, return to previous effective dose, slow the tapering schedule, and consider stress-dose steroids during periods of illness or stress 3
During periods of stress (illness, surgery, trauma), increase glucocorticoid dose temporarily, for example, for surgery: administer hydrocortisone 100 mg IV at start of surgery, followed by infusion of 200 mg/24h 3
For minor illness, double the regular oral replacement dose for 48h 3

Regular assessment of clinical symptoms, monitoring morning cortisol levels periodically, and evaluating for signs of recurrent Cushing's syndrome or adrenal insufficiency is crucial 1
Educate patients about steroid stress dosing, emergency injections, and medical alert identification 1
For patients with comorbidities, more careful monitoring is required, especially for those with asthma and diabetes, and patients with mineralocorticoid dependency require more cautious tapering 3