Prednisone taper 40 mg, prednisone taper 40 mg.

CORTICOSTEROIDS

  • $ = 0-$50, $$ = $51-$100, $$$ = $101-$150, $$$$ = > $150
  • Pricing based on a standard course of therapy (5 – 10 days) in a child or adult
  • Pricing found on GoodRX.com®
  • Pricing may vary by region and availability
  • References: Dexamethasone PI, Depo-Medrol PI
  • MECHANISM OF ACTION
  • Overview
    • Corticosteroids have a number of physiological effects throughout the body. They are essential for survival, and the body produces its own corticosteroid called cortisol. Cortisol is secreted by the adrenal gland in response to stimulation by ACTH. (See HPA axis)
    • Cortisol plays a key role in the body’s reaction to stress, injury, fasting, and inflammation
    • In high doses, corticosteroids suppress the immune system, and this why they are used to treat a wide range of diseases that are driven by inflammation
    • Effects of corticosteroids include the following:
      • Promotion of glucose production
      • Inhibition of glucose utilization and anti-insulin properties
      • Depression of eosinophils and lymphocytes
      • Stimulation of red blood cell production and polymorphonuclear leukocytes
      • Mobilization of fat stores
      • Increased urinary calcium excretion
      • Maintenance of normal vascular tone
      • Inhibition of wound healing
      • Retention of sodium and fluid, and loss of potassium (mineralocorticoid activity)

    Inflammatory conditions

    • Steroids are FDA-approved for the treatment of a large number of inflammatory conditions
    • Some common examples include:
      • Asthma and allergies
      • Rheumatoid arthritis
      • Lupus
      • Gout
      • Dermatitis and eczema
      • Crohn’s disease and ulcerative colitis
      • Kidney diseases (ex. Nephrotic syndrome)
      • Multiple sclerosis
      • Organ transplants
      • Idiopathic thrombocytopenia

    Adrenal insufficiency

    • Steroids are also used as replacement therapy in conditions where the body does not make sufficient amounts of cortisol (e.g. Addison’s disease).
  • OVERVIEW
    • Side effects of corticosteroids depend on the length of use
    • Short-term use does not typically have lasting effects
    • Chronic steroid therapy can have a number of adverse effects

    SHORT-TERM USE (Incidence not well-defined)

    • Increased appetite
    • Elevated blood sugar – in one study, prednisone 25 – 60 mg a day increased the 2hr GTT by ∼ 100 mg/dl in nondiabetics [2]
    • Increased blood pressure
    • Gastric irritation
    • Behavior and mood changes
    • Vaccines – live and attenuated vaccines are contraindicated in patients receiving immunosuppressive doses of corticosteroids. Responses to inactivated vaccines may be diminished. Common live vaccines include MMR, shingles (zoster), varicella (chickenpox), rotavirus, oral polio, influenza nasal vaccine (Flumist), yellow fever, and adenovirus.
    • HPA AXIS SUPPRESSION
      • Long-term steroid use can cause suppression of the HPA axis. HPA axis suppression leads to cortisol deficiency when exogenous steroids are withdrawn.
      • Tapering steroids may help prevent suppression. See tapering steroids below for more.
    • GASTRITIS AND PEPTIC ULCERS
      • Steroids can attenuate the stomach’s ability to protect itself against digestive acids. This can worsen or lead to gastritis and/or peptic ulcers.
      • Concomitant NSAIDs may increase the risk and should be avoided when possible
    • DIABETES
      • Corticosteroids raise blood sugar levels and may worsen diabetes
      • In one study, prednisone 25 – 60 mg a day increased the 2hr GTT by ∼ 100 mg/dl in nondiabetics [2]
      • Use steroids with caution in diabetics, particularly those who are uncontrolled
    • OSTEONECROSIS OF THE FEMORAL OR HUMERAL HEAD
      • Long-term steroid use may increase the risk of osteonecrosis of the femoral or humeral head
    • OSTEOPOROSIS
      • Long-term steroid use is a risk factor for osteoporosis
      • The mechanism appears to occur through calcium loss and direct effects on bone formation
      • See osteoporosis for more
    • INFECTION
      • Long-term steroid use suppresses immunity and may increase the risk of serious infection
    • HEART ATTACK
      • Steroids may increase the risk of ventricular free wall rupture in patients who have suffered a recent heart attack
    • STUNTED GROWTH
      • Long-term steroid use may suppress bone growth and stunt adult heights in children
      • This is true even for inhaled corticosteroids used in asthma. See inhaled corticosteroids for more.
    • MYASTHENIA GRAVIS
      • An acute myopathy has been observed with the use of high doses of corticosteroids in patients with myasthenia gravis
    • KAPOSI’S SARCOMA
      • Kaposi’s sarcoma has been reported in patients receiving corticosteroid therapy, most often for chronic conditions
      • Discontinuing steroids may lead to remission
    • SKIN TESTING
      • Steroids may suppress reactions to skin testing (e.g. PPD, allergy) and lead to false-negative interpretation
    • LIVER DISEASE
      • Steroids have not been studied extensively in liver disease. Use caution.
    • DRUG INTERACTIONS
    • NOTE: Drug interactions presented here are NOT all-inclusive. Other interactions may exist. The interactions presented here are meant to encompass commonly prescribed medications and/or interactions that are well-documented. Always consult your physician or pharmacist before taking medications concurrently. CLICK HERE for more information on drug interactions.
    • CYP3A4 inhibitors and inducers – corticosteroids are CYP3A4 substrates. CYP3A4 inhibitors may increase steroid levels and CYP3A4 inducers may decrease steroid levels.
    • NSAIDs (ibuprofen, naprosyn, aspirin, etc.) – NSAIDs may increase the risk of gastrointestinal side effects seen with steroids
  • METABOLISM AND ELIMINATION
    • NOTE: Drugs can be metabolized by more than one enzyme. Drugs may be metabolized by an enzyme and inhibit/induce the enzyme at the same time. Drug transporters (ex. p-glycoprotein) can play a role in drug metabolism. Not all drug interactions are clinically significant. Consult your physician or pharmacist if you are taking medications together and are concerned about a possible interaction.

  • OTHER
    • Thiazide diuretics – corticosteroids may worsen potassium loss from thiazide diuretics
    • Loop diuretics – corticosteroids may worsen potassium loss from loop diuretics
    • Anticholinesterase agents – Concomitant use of anticholinesterase agents and corticosteroids may produce severe weakness in patients with myasthenia gravis
    • Amphotericin B – corticosteroids may worsen the potassium loss caused by amphotericin B
    • Warfarin – corticosteroids may inhibit the effects of warfarin.
    • Isoniazid – corticosteroids may decrease isoniazid levels
    • Cholestyramine – cholestyramine may increase the clearance of corticosteroids
    • Cyclosporine – increased activity of both cyclosporine and corticosteroids may occur when the two are used concurrently
    • Digoxin – corticosteroids may increase the risk of arrhythmias due to hypokalemia
    • Estrogens and oral contraceptives – estrogens may decrease the hepatic metabolism of certain corticosteroids, thereby increasing their effect
    • Testosterone replacement therapies – testosterone may increase the fluid retention seen with corticosteroids. Use caution.
Asthma exacerbation – children
  • DRUG: Prednisone, Prednisolone, or Methylprednisolone
  • DOSING: 1 – 2 mg/kg/day given in 2 divided doses (maximum 60 mg/day). Give until PEF is 70% of predicted or personal best
  • OTHER:
    • For outpatient “burst,” use 1 – 2 mg/kg/day (maximum 60 mg/day) for 3 – 10 days
    • There is no known advantage for higher doses of corticosteroids in severe asthma exacerbations, nor is there any advantage for intravenous administration over oral therapy provided gastrointestinal transit time or absorption is not impaired.
    • The total course of systemic corticosteroids for an asthma exacerbation requiring an ED visit or hospitalization may last from 3 to 10 days. For corticosteroid courses of less than 1 week, there is no need to taper the dose. For slightly longer courses (e.g., up to 10 days), there probably is no need to taper, especially if patients are concurrently taking inhaled corticosteroids.
    • Inhaled corticosteroids can be started at any point in the treatment of an asthma exacerbation.
  • REFERENCE: NHLBI 2007 asthma guidelines

Asthma exacerbation – adults
  • DRUG: Prednisone, Prednisolone, or Methylprednisolone
  • DOSING: 40 – 80 mg/day in 1 or 2 divided doses until PEF reaches 70% of predicted or personal best
  • OTHER:
    • For outpatient “burst,” use 40 – 60 mg in single or 2 divided doses for total of 5 – 10 days
    • There is no known advantage for higher doses of corticosteroids in severe asthma exacerbations, nor is there any advantage for intravenous administration over oral therapy provided gastrointestinal transit time or absorption is not impaired.
    • The total course of systemic corticosteroids for an asthma exacerbation requiring an ED visit or hospitalization may last from 3 to 10 days. For corticosteroid courses of less than 1 week, there is no need to taper the dose. For slightly longer courses (e.g., up to 10 days), there probably is no need to taper, especially if patients are concurrently taking inhaled corticosteroids.
    • Inhaled corticosteroids can be started at any point in the treatment of an asthma exacerbation.
  • REFERENCE: NHLBI 2007 asthma guidelines

Bell palsy
  • DOSING: Prednisone 50 – 60 mg a day for 5 – 10 days
  • OTHER:
    • The American Academy of Neurology recommends corticosteroids for the treatment of new-onset (within 72 hours of symptoms onset) Bell palsy
    • See Bell palsy for more
  • REFERENCE:American Academy of Neurology 2012 recs, PMID 2316264

Crohn’s disease
  • DOSING:
    • Starting: Prednisone 40 – 60 mg once daily
    • Prednisone is given until resolution of symptoms which typically occurs within 7 – 28 days
    • Prednisone is then tapered by 5 – 10 mg/week down to 20 mg. From 20 mg, it is tapered by 2.5 – 5 mg/week until stopped.
  • OTHER:
    • The oral steroid budesonide is also used in Crohn’s disease. It has less systemic absorption and different recommendations. See budesonide for more.
    • See Crohn’s disease for more
  • REFERENCE:American College of Gastroenterology Crohn’s Disease Practice Guidelines 2009 [PMID 19174807]

Giant cell arteritis (GCA)
  • DOSING:
    • GCA without jaw or tongue claudication or visual symptoms:
      • Prednisolone or prednisone 40 – 60 mg (not < 0.75 mg/kg) daily for 4 weeks (may need longer course if symptoms and laboratory abnormalities have not resolved)
      • Then dose is reduced by 10 mg every 2 weeks to 20 mg
      • Then by 2.5 mg every 2 – 4 weeks to 10 mg
      • Then by 1 mg every 1 – 2 months provided there is no relapse
    • GCA with visual symptoms:
      • Evolving visual loss or history of amaurosis fugax: IV methylprednisolone 500 mg to 1 g daily for 3 days
      • Established vision loss: at least 60 mg prednisolone or prednisone daily
      • Continue for 4 weeks (may need longer course if symptoms and laboratory abnormalities have not resolved)
      • Then dose is reduced by 10 mg every 2 weeks to 20 mg
      • Then by 2.5 mg every 2 – 4 weeks to 10 mg
      • Then by 1 mg every 1 – 2 months provided there is no relapse
      • See giant cell arteritis for more
  • REFERENCE:British Society of Rheumatology GCA Treatment recs 2010 PMID 20371504

  • DOSING:
    • Systemic (one of the following):
      • Prednisone or prednisolone
        • Regimen 1 – at least 0.5 mg/kg/day for 5 – 10 days then discontinue
        • Regimen 2 – at least 0.5 mg/kg/day for 2 – 5 days, then taper for 7 – 10 days
      • Methylprednisolone (Medrol®) dose pack
    • Intramuscular
      • Triamcinolone acetonide 60 mg IM, followed by prednisone as above
      • IM triamcinolone may be given as monotherapy, but no consensus was reached on this recommendation
    • Intra-articular
      • Dosing should be based on size of the joint
      • Can be used in combination with NSAIDs, colchicine, or oral corticosteroids
      • See gout for more
  • REFERENCE:American College of Rheumatology 2012 Gout treatment recs PMID 23024029

Herpes zoster (shingles)
  • DOSING:
    • Prednisone 60 mg a day for 7 days, then 30 mg a day for 7 days, then 15 mg a day for 7 days, then discontinue
  • REFERENCE:Infectious Disease Society of America 2007 Herpes zoster treatment recs PMID 17143845

Immune Thrombocytopenia (ITP)
  • DOSING:
    • Children
      • First-line: Prednisone 1 – 2 mg/kg/day for a maximum of 14 days OR 4 mg/kg/day for 3 – 4 days
      • Nonresponders: High-dose dexamethasone 28 mg/m 2 /day

      Adults

      • First-line: Prednisone 1 mg/kg for 21 days then taper
      • See immune thrombocytopenia for more
  • REFERENCE: The American Society of Hematology 2011 evidence-based practice guideline for immune thrombocytopenia. PMID 21325604
Polymyalgia rheumatica
  • DOSING:
    • Prednisolone or prednisone 15 mg a day for 3 weeks
    • Then 12.5 mg for 3 weeks
    • Then 10 mg for 4 – 6 weeks
    • Then reduce by 1 mg every 4–8 weeks or alternate day reductions (e.g. 10/7.5 mg alternate days, etc.)
    • Typically, 1-2 years of treatment are needed
    • An alternative regimen with IM methylprednisolone is given as: 120 mg IM every 3-4 weeks, reducing by 20 mg every 2-3 months
    • See polymyalgia rheumatica for more
  • REFERENCE:British Society of Rheumatology PR Treatment recs 2010 PMID 19910443

Rheumatoid arthritis (RA)
  • DOSING:
    • The 2013 EULAR RA management recommendations state that corticosteroids for RA should be given at a dose ≤ 7.5 mg a day of prednisone or equivalent
    • The length of therapy is ideally ≤ 6 months
    • See rheumatoid arthritis for complete recommendations
    • Intra-articular corticosteroids may be appropriate in some patients
  • REFERENCE:European League Against Rheumatism RA management recs 2013, PMID 24161836

Sarcoidosis
  • DOSING:
      • Prednisone 20 – 40 mg a day for 6 – 12 weeks
      • Then taper to 5 – 10 mg a day
      • Typical treatment duration is 12 months, although course may be shortened in quick responders
      • See sarcoidosis for more information
  • REFERENCE: PMID 24090799, 10430755, 23596348

Ulcerative colitis
  • DOSING:
    • Initial therapy: Prednisone 40 – 60 mg once daily
    • Prednisone is given until significant improvement occurs
    • Prednisone is then tapered by 5 – 10 mg/week down to 20 mg. From 20 mg, it is tapered by 2.5 mg/week until stopped.
  • OTHER:
    • Budesonide is another steroid that is used to treat ulcerative colitis. It is available as a pill and as a rectal foam. The pill has less systemic absorption and different recommendations than other oral steroids. See budesonide for more.
    • Hydrocortisone foam and enemas are used as topical therapies to treat ulcerative colitis. See hydrocortisone for more.
    • See ulcerative colitis for more
  • REFERENCE:American College of Gastroenterology Ulcerative Colitis Practice Guidelines 2010 [PMID 20068560]

  • Overview
    • One of the biggest issues with corticosteroids is knowing when and how to taper steroids in order to prevent, or facilitate the correction of hypothalamic-pituitary-adrenal (HPA) axis suppression
    • There is surprisingly little information in the medical literature to help guide these decisions, and there is no consensus among experts on how it should be done
    • A study in the NEJM that was performed in 1992 found no significant correlation between the length or dose of steroid therapy and HPA axis suppression. The study included patients who had been taking steroids for a period of 1 week to 15 years. [3]
    • Given the dearth of information, tapering decisions have to be made on an individual patient basis
    • General principles of corticosteroid tapering:
      • Individuals can vary greatly in their susceptibility to HPA axis suppression
      • Length and dose of steroid therapy are imperfect predictors of HPA axis suppression
      • In general, most patients who have been on steroids for less than 4 weeks will have minimal or no HPA axis suppression, although suppression can still be seen in a small number of patients [3]
      • A simple tapering regimen for patients who have been on extended therapy is to reduce the dose of steroids by 10 – 20% every 1 – 2 weeks
      • Patients on corticosteroids for > 1 month should receive perioperative IV hydrocortisone to protect against adrenal insufficiency [4]
      • Symptoms of adrenal insufficiency include: hypotension, weakness, fatigue, hypoglycemia, decreased appetite, nausea and vomiting, low sodium, and mental changes
  • Short-term vs conventional glucocorticoid therapy in acute exacerbations of chronic obstructive pulmonary disease: the REDUCE randomized clinical trial – JAMA (2013) [PMID 23695200]
    • DESIGN: Randomized, placebo-controlled trial (N=311, length=180 days)
    • TREATMENT: Treatment with 40 mg of prednisone daily for either 5 or 14 days in a placebo-controlled, double-blind fashion
    • PRIMARY OUTCOME: Time to next exacerbation within 180 days
    • RESULTS:
      • Patients with reexacerbation within 180 days: 5-day Group – 36%, 14-day Group – 37%
      • Median time to reexacerbation: 5-day Group – 43.5 days, 14-day Group – 29 days
    • FINDINGS: In patients presenting to the emergency department with acute exacerbations of COPD, 5-day treatment with systemic glucocorticoids was noninferior to 14-day treatment with regard to reexacerbation within 6 months of follow-up but significantly reduced glucocorticoid exposure. These findings support the use of a 5-day glucocorticoid treatment in acute exacerbations of COPD.

  • Adjunct prednisone therapy for patients with community-acquired pneumonia: a multicentre, double-blind, randomised, placebo-controlled trial – Lancet (2015) [PMID 25608756]
    • DESIGN: Randomized, placebo-controlled trial (N=785, length=7 days)
    • TREATMENT: Prednisone 50 mg daily or placebo for 7 days
    • PRIMARY OUTCOME: The primary endpoint was time to clinical stability defined as time (days) until stable vital signs for at least 24 hours
    • FINDINGS: Prednisone treatment for 7 days in patients with community-acquired pneumonia admitted to hospital shortens time to clinical stability without an increase in complications. This finding is relevant from a patient perspective and an important determinant of hospital costs and efficiency.

  • StraightHealthcare analysis:
    • This study found that an oral steroid taper significantly improved function in patients with sciatica after 3 weeks. Steroids had no effect on pain.
    • The effect size was modest (6% difference in the ODI scale when compared to placebo), and it occurred at the cost of more side effects (insomnia, nervousness, increased appetite)
    • It’s important to note that because of steroid side effects, 75% of the subjects in the treatment group correctly identified their randomization group. This unblinding likely biased the study towards the treatment group and probably accounted for some of the effect seen. In addition, NSAIDs, a common treatment for sciatica, were not allowed during the active treatment phase, so it’s unclear how their use would have affected the results.
    • In conclusion, the effects of an oral steroid taper on sciatica are minimal at best and probably not worth the associated side effects in most patients
  • BMJ trial – Epidural injections vs sham injections, BMJ (2011) [PubMed abstract]
    • A trial in the British Medical Journal enrolled 116 patients with symptoms of disc disease for at least 12 weeks
    • Main inclusion criteria: unilateral sciatica for ≥ 12 weeks; age 20 – 60 years; intensity of the leg pain radiating from the back to below the knee comparable or worse than the back pain
    • Main exclusion criteria: severe pain; history of spinal injection or surgery; BMI > 30; treatment with NSAIDs
    • Baseline characteristics: average age 42 years; average BMI 26.4; MRI findings, disc herniation ∼ 65%, disc sequestration ∼ 33%
    • Patients were randomized to 1 of 3 groups:
      • Group 1 (40 patients) – Sham injections (2 mls of saline injected subcutaneously)
      • Group 2 (39 patients) – Caudal epidural saline injection (30 ml of saline)
      • Group 3 (37 patients) – Caudal epidural steroid injection (40 mg triamcinolone in 29 ml of saline)
      • All 3 groups received 2 injections 2 weeks apart
    • PRIMARY OUTCOME: change in score on the Oswestry Disability Index (ODI) at 6, 12, and 52 weeks. The ODI scale ranges from 0 – 100 with higher scores indicating more severe symptoms.
    • During follow-up, the following was seen:
      • Average ODI score at baseline: Group 1 – 26.3, Group 2 – 31.4, Group 3 – 32.5
      • For Group 1 (sham group), the average change in the ODI was -4.7 at 6 weeks, -11.4 at 12 weeks, and -14.3 at 52 weeks
      • The Group 2 (epidural saline) minus Group 1 differences were as follows: -0.5 at 6 weeks, +1.4 at 12 weeks, and -1.9 at 52 weeks (all nonsignificant)
      • The Group 3 (epidural steroid) minus Group 1 differences were as follows: -2.9 at 6 weeks, +4.0 at 12 weeks, and +1.9 at 52 weeks (all nonsignificant)
      • None of the comparisons at any time point were statistically significant. Analyses were adjusted for differences in baseline values.
      • Analyses adjusted for duration of leg pain, back pain, and sick leave were also nonsignificant
      • There were no serious complications from the injections [33]
  • StraightHealthcare analysis:
    • The BMJ trial above is the best trial we could find that evaluated the effects of spinal injections in disc disease. Another study detailed below (see anticonvulsants) found no benefit of injections when compared to gabapentin.
    • A number of other trials have been performed that have generally shown mixed results. Most of these studies did not use a sham control group which is crucial in evaluating this type of intervention.
    • Some authors maintain that steroid injections offer short-term (up to 6 week) relief of disc disease but have no lasting effect. This short-term effect may be due to systemic absorption of the steroid and is unrelated to steroid placement. A recent study of steroid injections in spinal stenosis found suppressed cortisol levels in patients receiving steroid injections (see spinal stenosis injections below). This finding supports a systemic effect. A blinded study comparing spinal injections to intramuscular steroid injections would be interesting.
    • In short, there is no conclusive evidence that spinal injections improve outcomes in disc disease

    Spinal stenosis

  • StraightHealthcare analysis:
    • This trial found no meaningful effect of epidural steroid injections on spinal stenosis
    • A significant difference was seen at 3 weeks, but this may have been due to systemic absorption of the steroids and unrelated to the placement of the injection around the spinal cord. The finding that cortisol levels were suppressed in patients receiving steroids supports the fact the steroids were absorbed and had a systemic effect. A trial comparing epidural steroid injections to an oral steroid taper would be interesting to determine if targeted steroid placement has any benefit at all.
    • Given the cost and potential risk of such procedures (deadly meningitis outbreak of 2012), steroid epidural injections should not be recommended for most patients with spinal stenosis
    • #PMID
    • 1 – 19940300
    • 2 – 16145005
    • 3 – 12759325
    • 4 – 8446138
    • 5 – 20821851
    • 6 – 19821314
    • 7 – 20091662
    • 8 – 20687095
    • 9 – 20448074
    • 10 – 17309946
    • 11 – Eplerenone PI
    • 12 – 15073471
    • 13 – 12842242
    • 14 – 19821398
    • 15 – 21073363
    • 16 – 12668699
    • 17 – 10471456
    • 18 – 12106936
    • 19 – 16160202
    • 20 – 21029871
    • 21 – 20010338
    • 22 – 8373706
    • 23 – 2046107
    • 24 – 18550938
    • 25 – European Association of Urology. Guidelines on Urolithiasis. 2011
    • 26 – 20818905
    • 27 – 11015164
    • 28 – 13679324
    • 29 – 2271853
    • 30- 2344503
    • 31 – 10653441
    • 32 – 9554680
    • 33 – 17904464
    • 34 – 6137813
    • 35 – 7388366
    • 36 – Demadex PI
    • 37 – 8432162
    • 38 – 21095025
    • 39 – 21285714
    • 40 – 16291814
    • 41 – 18946066
    • 42 – 11733620
    • 43 – 18413556
    • 44 – 16355285
    • 45 – 15656876
    • 46 – 19368583
    • 47 – 12639869
    • 48 – 10672134
    • 49 – 9665357
    • 50 – 9702848
    • 51 – 1486908
    • 52 – 5920655
    • 53 – 7752176
    • 54 – 4102452
    • 55 – 1486906
    • 56 – Bumetanide PI
    • 57 – Furosemide PI
    • 58 – 16036053
    • 59 – 16342656
    • 60 – Aldactone PI
    • 61 – 19843067
    • 62 – 2050832
    • 63 – 3661395
    • 64 – 6338681
    • 65 – 3189169
    • 66 – 19865106
    • 67 – 10199763
    • 68 – 7104176
    • 69 – 3884122
    • 70 – 8290411
    • 71 – 6409208
    • 72 – 6389077
    • 73 – 6619267
    • 74 – 7282751
    • 75 – 3521452
    • 76 – 1747638
    • 77 – 7431573
    • 78 – 19074530
    • 79 – 16035375
    • 80 – 15601807
    • 81 – 12011477
    • 82 – 20216123
    • 83 – 21193625
    • 84 – 14573734
    • 85 – 12020173
    • 86 – 14638621
    • 87 – 20010338
    • 88 – 21272751
    • 89 – removed
    • 90 – Natl Kidney Foundation Guidelines on Hypertension and Antihypertensive Agents in Chronic Kidney Disease. Click here
    • 91 – 20633946
    • 92 – 19475696
    • 93 – 19940300
    • 94 – 16801488
    • 95 – 19160242
    • 96 – 21975748
    • 97 – 12479763
    • 98 – 2318517
    • 99 – 22017784
    • 100 – 17101936
    • 101 – 16119971
    • 102 – 24352797

    Leave a Reply