Which strategy is effective to minimize development of HPA axis suppression in a patient with rheumatoid arthritis on long-term high-dose corticosteroid therapy?

Using alternate-day administration of corticosteroids can significantly minimize the development of hypothalamic-pituitary-adrenal (HPA) axis suppression in patients requiring long-term high-dose therapy for conditions like rheumatoid arthritis. This strategy allows the body some recovery time, enabling the adrenals to retain function and responsiveness.

When corticosteroids are administered daily at high doses, they can suppress the normal function of the HPA axis, leading to decreased endogenous cortisol production. By switching to an alternate-day regimen, the overall corticosteroid exposure is reduced, while still managing the condition effectively on a less frequent basis. This approach helps mitigate adrenal suppression and promotes a return of normal adrenal function during the off days.

In contrast, administration via topical or inhalation routes, while they may have localized effects and less systemic absorption, do not directly address the need for systemic steroid therapy in serious cases of rheumatoid arthritis where high doses are necessary. Immediate cessation of corticosteroids can lead to acute adrenal insufficiency, which is dangerous and generally not recommended without a gradual taper. Lastly, dividing the daily dose into two smaller doses may help in managing some symptoms but does not significantly prevent HPA axis suppression in the same way that alternate-day therapy does.