Corticosteroid Weaning in Stable Heart Transplant Patients: Guidance by Serum Cortisol Level.

David A Baran,Cheryl Rosenfeld,Mark J Zucker

doi:10.1155/2018/3740395

David A Baran, Cheryl Rosenfeld + Show 1 more

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https://doi.org/10.1155/2018/3740395

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Abstract

Background Despite earlier studies describing the feasibility of steroid weaning in heart transplant patients, the majority of patients are maintained on steroid therapy for life. We examined a strategy based on a single morning serum cortisol measurement. Methods We assigned stable posttransplant patients, who were maintained on tacrolimus, mycophenolate mofetil, and corticosteroids, into one of two groups based on a screening morning cortisol level. Patients with a cortisol < 8 micrograms/deciliter were assigned to a “maintenance” group and the others were assigned to the weaning group and steroids were tapered off over 4–6 weeks. Patients were monitored on subsequent office visits for adrenal insufficiency and allograft rejection. Results Thirty-one patients were enrolled (6 patients in the maintenance group and 25 in the steroid-weaning group). Mean follow-up was 10.2 ± 4 years for the weaning group and 9.0 ± 4.9 years in the maintenance group (p = 0.6). No cases of rejection were noted, nor did any patient resume steroid treatment following discontinuation. Conclusion Steroids can be safely discontinued in stable heart transplant patients with an AM serum cortisol ≥ 8 micrograms/deciliter with appropriate outpatient follow-up. In this study, no patient suffered late rejection or clinically noted adrenal insufficiency.

Highlights

Corticosteroids have been an integral part of immunosuppression regimens since the beginnings of clinical transplantation [1, 2]
While some early studies described the feasibility of steroid weaning [6,7,8,9,10], the idea has not been embraced, and International Society for Heart and Lung Transplantation (ISHLT) registry data indicates that more than 60% of patients are chronically maintained on corticosteroids [11]
Six patients had a morning serum cortisol less than 8 micrograms/deciliter and were assigned to the maintenance group, and 25 patients were assigned to the steroid-weaning group

Summary

Introduction

Corticosteroids have been an integral part of immunosuppression regimens since the beginnings of clinical transplantation [1, 2]. While some early studies described the feasibility of steroid weaning [6,7,8,9,10], the idea has not been embraced, and International Society for Heart and Lung Transplantation (ISHLT) registry data indicates that more than 60% of patients are chronically maintained on corticosteroids [11]. The fear of allograft rejection and the concern about “unmasking” occult adrenal insufficiency are the main clinical reasons that more patients are not routinely discontinued from steroid therapy [7, 12, 13]. Despite earlier studies describing the feasibility of steroid weaning in heart transplant patients, the majority of patients are maintained on steroid therapy for life. Steroids can be safely discontinued in stable heart transplant patients with an AM serum cortisol ≥ 8 micrograms/deciliter with appropriate outpatient follow-up. No patient suffered late rejection or clinically noted adrenal insufficiency

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