How soon can someone restart corticosteroids (steroids) after completing a taper?

From the Guidelines

Restarting corticosteroids after completing a taper should be done with caution, and the decision to restart should be based on the individual patient's condition and the risk of adrenal suppression, with a general recommendation to wait at least 1-2 weeks before restarting steroids, as suggested by recent guidelines 1. The timing for restarting corticosteroids after completing a taper depends on the specific medical condition and individual patient factors. For conditions like immune-related adverse events, guidelines suggest that corticosteroids can be tapered after 2-4 weeks, monitoring for symptom recurrence 1.

Key Considerations

• The hypothalamic-pituitary-adrenal (HPA) axis needs time to recover from the previous course of steroids, which can take several weeks 1.
• Repeated or prolonged steroid use can lead to adrenal suppression, where the body becomes dependent on external steroids and cannot produce adequate cortisol naturally.
• Patients who have recently completed a steroid taper should monitor for signs of the underlying condition worsening and consult their healthcare provider before restarting steroids.
• For those requiring frequent steroid courses, steroid-sparing agents or alternative treatments might be considered to minimize long-term steroid exposure and associated side effects.

Specific Conditions

• For immune-related adverse events, resuming ICPi after symptoms improve to grade 1 may be considered when steroid taper is completed, and risk and benefits are reviewed 1.
• For conditions like asthma or COPD exacerbations, physicians may restart prednisone at 20-40mg daily if symptoms recur, while for inflammatory conditions like rheumatoid arthritis, a longer interval of 2-4 weeks may be preferred.

General Guidance

• A minimum waiting period of 1-2 weeks is recommended before restarting corticosteroids after completing a taper.
• The decision to restart corticosteroids should be based on the individual patient's condition and the risk of adrenal suppression.
• Patients should be closely monitored for signs of adrenal suppression and other side effects of steroid use.

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.

The FDA drug label does not provide a specific time frame for when someone can restart corticosteroids after completing a taper. However, it does mention that adrenocortical insufficiency may persist for up to 12 months after discontinuation of therapy, and hormone therapy should be reinstituted in case of stress during this period 2.

• It is recommended to individualize and tailor the therapy to each patient.
• Complete control of symptoms will not be possible in all patients.
• The patient should be warned not to discontinue the use of corticosteroids abruptly or without medical supervision 2.
• Patients should be advised to seek medical advice at once should they develop an acute illness, including fever or other signs of infection 2.

From the Research

Restarting Corticosteroids after a Taper

• The decision to restart corticosteroids after a taper depends on various factors, including the underlying condition being treated, the duration of corticosteroid use, and the individual patient's response to the taper 3.
• There is no one-size-fits-all answer to how soon someone can restart corticosteroids after completing a taper, as it depends on the specific clinical scenario and the patient's overall health status.
• In general, the hypothalamic-pituitary-adrenal (HPA) axis can take several weeks to several months to recover after prolonged corticosteroid use, and restarting corticosteroids too soon can increase the risk of adrenal insufficiency 3, 4.

Factors Influencing Restarting Corticosteroids

• The duration of corticosteroid use is an important factor in determining how soon someone can restart corticosteroids after a taper, with longer durations of use requiring longer taper periods and more cautious restart strategies 3, 5.
• The dose and type of corticosteroid used can also influence the restart strategy, with higher doses and longer-acting corticosteroids requiring more gradual tapers and longer recovery periods 6, 7.
• Individual patient factors, such as age, comorbidities, and overall health status, can also impact the decision to restart corticosteroids and the optimal restart strategy 3, 4.

Clinical Evidence

• Studies have shown that rapid corticosteroid tapers can be effective in certain clinical scenarios, such as immune checkpoint inhibitor-induced nephritis, without increasing the risk of adverse outcomes 7.
• Other studies have found that slower tapers may be necessary in certain situations, such as in patients with a history of adrenal insufficiency or those who have been on long-term corticosteroid therapy 3, 5.
• The optimal restart strategy will depend on the specific clinical context and should be guided by clinical judgment and evidence-based guidelines 3, 6, 4, 7.