In this episode, I’ll discuss medications commonly tapered in the ICU.
Three classes of medications that are frequently considered for tapering in the ICU are:
-Corticosteroids
-Opioids
-Benzodiazepines
For each of these classes, I will cover why, when, and how to taper them:
Corticosteroids
Why taper corticosteroids
Corticosteroids are tapered for two different reasons:
1. To minimize adrenal insufficiency from hypothalamic-pituitary-adrenal (HPA) axis suppression.
2. To prevent a flare-up of the condition the steroids were being used to treat.
When to taper corticosteroids
Significant HPA axis suppression does not typically occur unless corticosteroids are given continuously for at least 3 weeks at a dose equivalent to 7.5 mg or more of prednisone daily. Continuous corticosteroid administration at these doses suppresses production of corticotropin-releasing hormone and corticotropin and may lead to atrophy of the adrenal gland. Abrupt cessation of steroids in this setting may lead to adrenal insufficiency.
When given for COPD exacerbation, corticosteroids are often tapered to avoid a flare-up or rebound exacerbation. This is probably unnecessary unless the patient was taking chronic steroids prior to being treated for an exacerbation.
When using corticosteroids for the treatment of septic shock, the typical duration of 5-7 days is not long enough for significant HPA axis suppression to occur. Corticosteroids in this case only need to be tapered if hemodynamic instability occurs when they are stopped.
How to taper corticosteroids
When chronic corticosteroids are tapered to prevent adrenal insufficiency, the dose may be decreased by 5-20% every 1 to 2 weeks. I only taper on the aggressive end of this range if there is an urgent need for the taper.
In patients who received steroids for septic shock, discontinuation occurs after the patient has been off vasopressors for 24 hours. If hemodynamic instability recurs, I resume the steroids and taper them over the course of a few days in 25-50% increments.
Opioids
Why taper opioids
Withdrawal from opioids is unpleasant for a patient but not directly life-threatening. Opioids may be tapered for 3 reasons:
1. Maintain the patient’s comfort by not causing withdrawal.
2. Maintain the staff’s safety if the patient may become agitated during withdrawal.
3. Avoid another disease being complicated by the symptoms of opioid withdrawal (for example the catecholamine surge from opioid withdrawal may worsen a myocardial infarction).
When to taper opioids
After approximately 7 days of continuous opioid use, a patient is at risk of withdrawal if opioids are suddenly stopped. It is important to note that there is no guarantee that any particular patient will experience withdrawal after this time point. Therefore, the speed at which opioids are tapered may be adjusted depending on the risk to the patient should they experience withdrawal symptoms.
In the ICU this typically occurs in patients who have been on a fentanyl infusion for sedation for 7 or more days.
How to taper opioids
I discussed how to taper a fentanyl infusion in detail in episode 72.
When I am in a hurry to taper the fentanyl drip so a patient can be moved to a lower level of care, I’ll use methadone 10 mg enterally (or 5 mg IV) every 6 hours. The fentanyl infusion can usually be rapidly tapered off after 1 or 2 doses of methadone have been given.
If I have enteral access for medications and there is no time-pressure to discontinue the opioid infusion, I’ll use enteral oxycodone. I usually give a scheduled dose and a prn dose of oxycodone in case withdrawal symptoms develop.
If enteral opioids cannot be used and there is no rush to get the patient off a fentanyl infusion, I’ll just taper the infusion as quickly as the patient will tolerate.
Often a large initial decrease in infusion rate can be made such as 50%. After that, the drip can be tapered in 25 mcg/hr increments at intervals that are at least several hours apart. If at any time the patient develops symptoms of withdrawal, return to the previous rate and consider giving an IV bolus of fentanyl.
Benzodiazepines
Why taper benzodiazepines
Of the many potential symptoms from withdrawal of benzodiazepines, seizure is the most significant. Loss of consciousness during a seizure may lead to loss of airway control. This in turn can lead to respiratory failure and death.
When to taper benzodiazepines
An ICU patient that was continuously sedated with a midazolam infusion for several weeks probably does not require tapering. Benzodiazepines must be used for a significant amount of time before the risk of withdrawal and the need for tapering is significant. For most benzodiazpines this occurs with use over 1 year in duration. For patients taking high doses or short acting benzodiazepines such as alprazolam, tapering may need to occur after 12 weeks of use.
How to taper benzodiazepines
There are many taper schedules for benzodiazepines. Tapering by 10% per week is usually a safe option. Some patients may tolerate faster initial tapers such as 25% in the first and second week before slowing back down to 10% per week. Yet another option is to convert a patient to a long acting benzodiazpine such as diazepam or clonazepam and taper slowly from there. The important part is not the option that is chosen, but that seizures are prevented. Besides seizure, symptoms such as anxiety, agitation, sweating, tachycardia, tremor, insomnia, nausea, vomiting, or hallucinations may indicate the taper is proceeding too quickly.
If you like this post, check out my book – A Pharmacist’s Guide to Inpatient Medical Emergencies: How to respond to code blue, rapid response calls, and other medical emergencies.
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