From the Guidelines
Abruptly stopping prednisone without a proper taper can lead to adrenal insufficiency, a potentially life-threatening condition, characterized by hypotension, hyponatraemia, and hypoglycaemia, as well as an increased risk of short-term surgical complications, including a five-fold risk of infectious complications 1. When prednisone is taken for more than a few weeks, the body reduces its natural production of cortisol, and stopping suddenly leaves the body without adequate steroid hormones.
Key Considerations
- The risk of adrenal insufficiency is higher in patients taking more than 20 mg of prednisolone for > 6 weeks 1.
- Symptoms of adrenal insufficiency include fatigue, weakness, dizziness, nausea, vomiting, low blood pressure, and in severe cases, shock or even death.
- A proper prednisone taper typically involves gradually reducing the dose over weeks or months, depending on the initial dose and duration of treatment, to avoid acute steroid withdrawal 1.
- For patients who have been taking steroids > 6 months, a dose reduction of 1 mg/week over a period of several months might be necessary 1.
Clinical Implications
- Patients should never stop prednisone suddenly without medical guidance, even if experiencing side effects.
- Patients on long-term steroid therapy should wear medical identification to ensure proper emergency treatment.
- The original condition being treated may flare up or worsen if prednisone is stopped abruptly.
From the FDA Drug Label
Adrenocortical insufficiency may result from too rapid withdrawal of corticosteroids and may be minimized by gradual reduction of dosage This type of relative insufficiency may persist for up to 12 months after discontinuation of therapy; therefore, in any situation of stress occurring during that period, hormone therapy should be reinstituted. 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, they should advise any medical attendants that they are taking corticosteroids and they should seek medical advice at once should they develop an acute illness including fever or other signs of infection Following prolonged therapy, withdrawal of corticosteroids may result in symptoms of the corticosteroid withdrawal syndrome including, myalgia, arthralgia, and malaise.
Without a prednisone taper, adrenocortical insufficiency may occur due to the body's dependence on the corticosteroid. This can lead to symptoms such as:
- Myalgia
- Arthralgia
- Malaise It is essential to gradually reduce the dosage of prednisone to minimize the risk of adrenocortical insufficiency and other withdrawal symptoms 2.
From the Research
Risks of Not Tapering Prednisone
- Without a proper taper, patients may experience adrenal insufficiency, which can be life-threatening 3
- The risk of acute adrenal crises secondary to glucocorticoid withdrawal can be fatal and arises from chronic suppression of the adrenal glands 3
- Adrenal insufficiency (AI) is a life-threatening condition requiring life-long glucocorticoid (GC) substitution therapy, as well as stress adaptation to prevent adrenal crises 4
- Discontinuing oral glucocorticoids without a taper can lead to increased morbidity and decreased life expectancy due to both increased exposure to cortisol and insufficient cortisol coverage during infections and other stress-related events 5
Consequences of Sudden Stoppage
- Sudden stoppage of prednisone can lead to adrenal crisis, which can be fatal if not treated promptly 3, 4
- Patients with adrenal insufficiency have a higher mortality than the general population, possibly because of excess glucocorticoid exposure at inappropriate times 6, 5
- The cortisol circadian rhythm is difficult to mimic with twice- or thrice-daily hydrocortisone, and prednisolone is a once-daily alternative which may improve patient compliance through its convenience 6
Importance of Tapering
- Tapering prednisone is crucial to prevent adrenal insufficiency and adrenal crisis 3, 4
- A gradual taper can help the adrenal glands recover and reduce the risk of adrenal insufficiency 3
- Low-dose prednisolone of 2-4 mg is safe and effective in most patients with AI, and doses can be titrated with either 4-, 6-, or 8-h single time point drug levels 6