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PJ Nicholoff Steroid Protocol Background/Assessment Normal basal secretion of cortisol from the adrenal gland is approximately 5-7 mg/m2/day or 8 -10 mg/day for adults. This amount increases during minor il nesses or surgery to approximately 50 mg/day (5x normal physiologic secretion). These smal increases with uncomplicated surgery return to baseline in 24 hours. Procedures producing greater surgical stress, have been shown to increase cortisol responses to 75-150 mg/day (10x normal physiologic secretion), which return to baseline in about 5 days. Corticosteroids are prescribed for multiple diagnoses to a wide variety of patients. Long term administration of corticosteroids may lead to suppression of the hypothalamic-pituitary-adrenal (HPA) axis. Rapid reduction or abrupt withdrawal of corticosteroid therapy that has been prolonged or at high doses can cause secondary adrenal insufficiency (suppression of the HPA axis), and steroid withdrawal or deprivation syndrome. Recovery from suppression of the HPA axis after discontinuing corticosteroids can be prolonged (possibly 6 to 12 months) and may vary based on doses, dosing schedules and duration of corticosteroid therapy. Since there is a great deal of individual variability in susceptibility to suppression of the HPA axis after chronic use of exogenous corticosteroids, it is not possible to predict with confidence which patients wil be affected. Current practice is to administer supplemental (stress) doses of corticosteroids to patients with suspected suppression of the HPA axis in the perioperative period and during acute il ness to prevent acute adrenal insufficiency, or adrenal crisis. Defining HPA Suppressed Patients: Recommendations differ slightly in defining a suppressed patient, but general guidelines are below (Table 1):

Suppression of HPA axis? Equivalents/day - Adults Equivalents/Day - Pediatric 3 mg/m2/day or less Usual y not suppressed. Possibly suppressed. ACTH stimulation test recommended or give supplemental dose. 20 mg/day for >10 days or 12 mg/m2/day of prednisone Suppressed. Give supplemental more for > 10 days or more Patients receiving disease appropriate corticosteroid doses (at least 10 times above the physiologic cortisol dose) general y do not need stress doses if usual daily dose is continued. Patients who are on maintenance physiologic dose of hydrocortisone for primary disease of the HPA axis do require supplemental therapy. Consultation with endocrinology is recommended for questions or concerns. Recommendations for supplemental doses are general y divided by severity of stress the patient may experience (medical or surgical). Supplemental steroid doses are then based on degree of stress. Corticosteroid Stress Doses: Medical/Surgical Stress Corticosteroid Dosage DOS* Postoperative Taper Regimen Minor (local anesthesia, < 1 25mg or 30-50 mg/m2 po (if able to take po) or IV Resume maintenance (e.g. inguinal hernia, single tooth hydrocortisone (HC) or physiologic dose of extraction, colonoscopy), mild hydrocortisone when il ness, febrile il ness, mild, pain or fever subsides nausea/vomiting, mild diarrhea) 50mg or 50-75 mg/m2 IV (e.g. multiple teeth extraction, hydrocortisone or equivalent mg/m2/day ÷ q 6 hours X 24 fracture, pneumonia) hour. Taper to baseline over 1-2 days. 100mg or 100 mg/m2/dose (e.g. Septic shock, multiple IV hydrocortisone or mg/m2/day ÷ q 6 hours X 24- trauma/fractures or severe burns, equivalent 48hours. Taper to baseline severe systemic infections, major over 1-3 days (continue stress surgery, pancreatitis, orthopedic dose if the physical stress surgery including open reduction, spinal fusion, etc.) (fever or pain) continues). DOS - Day of surgery

Patients using high dose twice-weekly corticosteroid-dosing schedule: • If patients using a twice-weekly dosing schedule are unable to take corticosteroids by mouth during a time when they should be taking corticosteroids (due to nausea, vomiting, diarrhea, etc.), patients should take stress doses intravenously as indicated above. • If patients using a twice weekly dosing schedule are undergoing/experiencing a moderate or major medical/surgical stressor in their life, cortisol level should be drawn and it is recommended that they follow the stress dosing recommendations in the above table. • No literature exists for these recommendations. The recommendations are based on expert opinion and practice. Recommendation for Corticosteroid Therapy Withdraw: Below is one recommendation for tapering chronic corticosteroids (general y managed in an outpatient setting): • Start on a Monday, giving 20-25% lower corticosteroid dose for 2 weeks (or • If multiple doses are taken, start first to reduce multiple daily doses to a single o Cut the dose 20-25% again for 2 weeks (or longer); continue this o Continue until dose is near physiologic dose (3mg/m2/day of prednisone or 3.6mg/m2/day of Deflazacort) • When near physiologic dose, substitute corticosteroids with short acting form of corticosteroid or hydrocortisone (12 mg/m2/day of hydrocortisone) • This wil also enable the patient to have a supply of hydrocortisone to be used for stress doses if needed in times of stress after coming off steroids o Continue to taper off by 20-25% each week (or longer) o Give every other day for 2 weeks (or longer) o Stop o WATCH VERY CAREFULLY FOR SIGNS OF ADRENAL CRISIS (see below) • Alert parents to signs/symptoms of adrenal crisis • If patients have symptoms of adrenal insufficiency during the taper, the steroid dose prior to the taper should be maintained for longer IF THE PATIENT HAS A SERIOUS ILLNESS/INJURY DURING THE TAPER, THEY MAY NEED A "STRESS DOSE" OF CORTICOSTEROIDS: • Encourage parents to continue to report any serious events until 1 year post-

o The stress doses of hydrocortisone is 30-50 mg/m2/day, or higher, for major stress (see Table 2) o Patients need to go to the emergency room if having signs or symptoms of adrenal crisis. Serum electrolytes with blood glucose and cortisol level should be obtained. o Patients should see a pediatric endocrinologist for evaluation of HPA axis during the process of corticosteroid therapy withdrawal. Patients using high dose twice-weekly corticosteroid-dosing schedule: • It is recommended that patients electing to discontinue the use of twice weekly corticosteroids, do so under the guidance of a neuromuscular provider and/or endocrinologist. • No literature exists for these recommendations. The recommendations are based on expert opinion and practice Testing HPA axis: • After reaching half the physiological dose (5-6 mg/m2/day of hydrocortisone or 1-1.5 mg/m2/day of prednisone), morning serum cortisol and ACTH should be assayed monthly (may do less frequently), until they reach normal levels. • When baseline morning serum ACTH and cortisol are normal, discontinue the corticosteroid and carry out the rapid ACTH stimulation test monthly until post-stimulation cortisol response is normal (post-stimulus level > 20 mcg/dL). When this point is reached, it can be considered that the HPA axis has recovered Modification of above protocol: • Omit monthly AM cortisol and ACTH and perform an ACTH stimulation test in 3 months after discontinuation of corticosteroids • During this time (3 months before getting ACTH stimulation test), patients wil need to take stress dose at the time of stress • If ACTH stimulation test result is abnormal (peak cortisol <20), patients wil need to continue taking stress doses of hydrocortisone at the time of stress. (Patients Repeat ACTH stimulation test again in 1-2 months later and families would need to have teaching on this with an endocrine nurse.) Alternatively, when laboratory tests cannot be carried out: • Patients who have used corticosteroids for prolonged periods can be considered as having suppression of the HPA axis up to 1 year after discontinuation of corticosteroid therapy and therefore need hydrocortisone stress dose coverage during the time of stress

Risk factors for adrenal crisis include: • Dehydration • Infection and other physical stress • Injury to the adrenal or pituitary gland • Stopping treatment too suddenly with glucocorticoid medications such as prednisone hydrocortisone • Surgery • Trauma Symptoms of adrenal crisis can include any of the fol owing: • Abdominal pain • Shock • Confusion or coma • Dehydration • Dizziness or light-headedness • Fatigue • Flank pain • Headache • High fever • Loss of appetite • Loss of consciousness • Low blood pressure • Nausea • Profound weakness • Rapid heart rate • Rapid respiratory rate (see tachypnea) • Slow, sluggish movement • Unusual and excessive sweating on face or palms • Vomiting Exams and Tests Tests that may be ordered to help diagnose acute adrenal crisis include: • ACTH (cosyntropin) stimulation test • Cortisol level • Blood sugar • Serum potassium • Serum sodium • Serum pH

Corticosteroid Conversion Table Equivalent doses Methyl prednisone 1. Hal man MR, Head DE, Coursin DB, Joffe AM. (2013) When and why should perioperative glucocorticoid replacement be administered? Evidence-Based Practice of Anesthesiology. Philadelphia, PA. Elsevier. 2. Marik PE, Varon J. Requirement of perioperative stress doses of corticosteroids. Arch Surg. 2008;143(12):1222-1226. 3. Kohl BA, Schwartz S. Surgery in the patient with endocrine dysfunction. Med Clin N Am. 2009;93:1031-1047. 4. Jaffer AK, Grant PJ. Perioperative Medicine: Medical Consultation and Comanagement. Hoboken, NJ: John Wiley & Sons Inc.;2012 5. 5.Hamrahian AH, Roman S, Milan S. The surgical patient taking glucocorticoids.In: UpToDate, Martin KA, Collins KA(Ed), UpToDate, Waltham, MA, 2014. 6. Stewart PM. The adrenal cortex. In: Larsen PR, Kronenberg HM, Melmed S, Polonsky KS, eds. Wil iams Textbook of Endocrinology. 10th ed. Philadelphia, PA: Saunders; 2003:491–551 7. Patient/Parent information: Acute adrenal crisis. Acknowledgements • St. Vincent's Hospital, Indianapolis, IN • Dr. Philip Zeitler, Children's Hospital Colorado, Aurora, CO • Dr. Sasigarn Bowden, Nationwide Children's Hospital, Columbus, OH • Dr. Doug Biggar, Hol and Bloorview Kids Rehab, Toronto, ON • Dr. Jerry Mendel , Nationwide Children's Hospital, Columbus, OH • Dr. Anne M. Connol y, St. Louis Children's Hospital, St. Louis, MO In honor of the late Philip James "PJ" Nicholoff, for his contribution to the global Duchenne community.

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