From the Guidelines
You can generally prescribe up to 14 days of steroids without needing to taper the dose, but for longer courses, tapering is recommended to prevent adrenal insufficiency. When considering the management of patients on steroid therapy, it's essential to weigh the benefits of treatment against the potential risks, including adrenal suppression. According to the most recent and highest quality study, 1, the optimal duration of glucocorticoid therapy is not well established, and the duration of therapy should be guided by the patient's clinical condition, values, and preferences.
Key Considerations
- For short-term systemic corticosteroid therapy, medications like prednisone, methylprednisolone, or dexamethasone can be stopped abruptly after 14 days in most patients without significant risk of adrenal suppression 1.
- However, for longer courses (beyond 2 weeks), higher doses, or in patients with known adrenal issues or who have received multiple recent steroid courses, tapering is recommended to prevent adrenal insufficiency 1.
- A typical taper might reduce the dose by 5-10mg every 3-7 days, and patients with chronic conditions requiring long-term steroids should always receive a tapering schedule 1.
Tapering Steroids
When tapering steroids, it's crucial to consider the patient's individual needs and clinical condition. The physiological basis for tapering is that short courses don't typically cause significant hypothalamic-pituitary-adrenal axis suppression, while longer exposure can lead to adrenal atrophy and reduced endogenous cortisol production, necessitating gradual withdrawal to allow the body to resume normal cortisol production 1.
Clinical Decision-Making
In clinical practice, the decision to taper steroids should be based on the patient's response to treatment, the presence of any adverse effects, and the risk of adrenal insufficiency. By considering these factors and following a gradual tapering schedule, clinicians can minimize the risks associated with steroid therapy and optimize patient outcomes.
From the FDA Drug Label
If steroid therapy is continued for more than 6 weeks, intraocular pressure should be monitored. Patients should be warned not to discontinue the use of corticosteroids abruptly or without medical supervision As prolonged use may cause adrenal insufficiency and make patients dependent on corticosteroids
The FDA drug label does not provide a specific number of days for steroid use before worrying about titrating down. However, it does mention that prolonged use can cause adrenal insufficiency and that patients should not discontinue use abruptly. It also mentions that if steroid therapy is continued for more than 6 weeks, intraocular pressure should be monitored.
- Key consideration: The risk of complications, such as adrenal insufficiency, increases with the duration and dose of treatment.
- Clinical decision: It is recommended to use the smallest possible effective dosage and duration to minimize the risk of glucocorticoid-induced side effects 2.
- Monitoring: Patients on long-term steroid therapy should be closely monitored for signs of adrenal insufficiency and other potential side effects.
From the Research
Steroid Tapering Guidelines
The decision to taper steroids depends on various factors, including the duration of steroid use, dosage, and individual patient response.
- According to the study 3, an 8-day course of 40 mg/day prednisolone did not show significant differences in relapse rate or adrenal suppression compared to a tapering dose.
- However, the study 4 suggests that long-term corticosteroid use can lead to secondary adrenal insufficiency, and the optimal strategy for tapering steroids remains to be defined.
- A structured schedule for tapering glucocorticoid treatment, as described in the study 5, can reduce the risk of adrenal crisis and acute adrenal insufficiency in patients with severe COVID-19.
Duration of Steroid Use and Tapering
- The study 6 found that there is no high-level evidence to guide tapering until discontinuation after extended courses of medium- to high-dose treatment regimens.
- The study 7 aims to demonstrate the clinical noninferiority and safety of abrupt treatment cessation after ≥28 days of systemic glucocorticoid therapy in patients with stabilized underlying disease.
Key Considerations
- The risk of adrenal insufficiency must be considered after glucocorticoid withdrawal, as it is a life-threatening condition if left unrecognized and untreated 5.
- A morning serum cortisol level below a certain threshold can indicate adrenal insufficiency, and patients should be monitored for signs and symptoms of hypocortisolism 5, 7.