Easy question: prednisone, taper off at 5 mg?

[whopper]

OK before anyone points out that this is a really easy question...I'm a psychiatry resident and we often don't deal with this.

Got a patient with rheumatoid arthritis. He's on prednisone 5 mg PO Q daily.

He's also depressed, but with racing thoughts.

Corticosteroids as most of us know can exacerbate or cause psychiatric sx. I'm going to have to evalute how much of the prednisone is involved in this.

But if I were to take him off of it (he's been on it for months) do I taper him off at 5mg being that its a low dose, of do I just DC it?

[gutonc]

Originally Posted by whopper

OK before anyone points out that this is a really easy question...I'm a psychiatry resident and we often don't deal with this.

Got a patient with rheumatoid arthritis. He's on prednisone 5 mg PO Q daily.

He's also depressed, but with racing thoughts.

Corticosteroids as most of us know can exacerbate or cause psychiatric sx. I'm going to have to evalute how much of the prednisone is involved in this.

But if I were to take him off of it (he's been on it for months) do I taper him off at 5mg being that its a low dose, of do I just DC it?

Does your hospital not have endo consult?

I think a taper would be wise for someone on chronic (even "low-dose") steroids. You don't want to add iatrogenic adrenal insufficiency to this dude's problem list.

BE

[Hernandez]

There is no clear guildines that I've seen on this, however, I'm not an authoritative source. books like Current Rheum reccomendes reductions "at a rate of 2.5 mg every week or 5 mg every other week. Most clinicians taper very slowly (1 mg per month) when the daily dose is 10 mg or less."

[inositide]

The length and dose of taper depends on the patient's age, so please tell us the patient's age.

There are certainly well known reports of delirium occurring upon discontinuation of system steroids like oral prednisone, but there are not too many reports out there about steroids causing or exacerbating acute depression.

If the patient has rheumatoid arthritis, then discontinuing steroids even after a taper might result in an acute arthritis exacerbation which can be quite painful and require even higher dose steroids to acutely manage.

Before you discontinue the prednisone, I suggest trying to rule out all other etiologies for the patient's psychiatric problems, and getting a rheumatology consult. You dont need an endocrine consult, but rheum consult should be done. The rheum consultant could also informally tell you about the best way to taper the prednisone because prednisone is really bread and butter for rheumatologists. Also, you could ask the rheum doc informally about his/her experience with chronic steroid patients and psychiatric problems.

[Annette]

This isn't an easy question. Why is the patient on prednisone? If it is for rheumatoid arthritis, stopping the prednisone may provoke a flare. If it is for lupus, you could kill off his kidneys with lupus nephritis.

Best bet is to consult the patient's rheumatologist.

[Crypt Abscess]

I think that chronic low dose steroids are very unlikely to be causing his psychiatric symptoms (racing thoughts). Every case of steroid induced mania or psychosis I have seen have involved acute, high dose steroids (100-200 mg/d).

Tapering chronic low dose steroids should be done very slowly- probably 1 mg every other week. Just my .02

[Furrball2]

Theoretically 5 mg qday prednisone is physiologic ( equivalent to 25 mg qday hydrocortisone), so I doubt that a physiologic replacement dose of prednisone would cause steroid delerium. But if you really want to stop the prednisone do a cort stim test and see if his hypothalamic-adrenal axis is still intact; and then stop the steroids. Or maybe the guy has just developed a really severe quetiapine deficiency, or maybe he has a CNS vasculitis 2/2 to his RA?

[Crypt Abscess]

I agree 5 mg/d is probably physiologic and a cortisol stim test is a good idea; HOWEVER, I think the patient would need to be switched to an equivalent dose of dexamethasone as prednisone interferes with the cortisol assay.

Originally Posted by Furrball2

Theoretically 5 mg qday prednisone is physiologic ( equivalent to 25 mg qday hydrocortisone), so I doubt that a physiologic replacement dose of prednisone would cause steroid delerium. But if you really want to stop the prednisone do a cort stim test and see if his hypothalamic-adrenal axis is still intact; and then stop the steroids. Or maybe the guy has just developed a really severe quetiapine deficiency, or maybe he has a CNS vasculitis 2/2 to his RA?

[Furrball2]

Originally Posted by Crypt Abscess

I agree 5 mg/d is probably physiologic and a cortisol stim test is a good idea; HOWEVER, I think the patient would need to be switched to an equivalent dose of dexamethasone as prednisone interferes with the cortisol assay.

I still say quetiapine deficiency , but you're' right about the dex. Or maybe it's just delerium on top of everything else, it has been known to happen.