From the Guidelines
The tapering regimen for stress dose steroids should be done over 5-7 days, starting with a high dose of hydrocortisone 50-100 mg intravenously every 6-8 hours, then transitioning to oral maintenance doses. For patients who have received high-dose steroids during acute stress or illness, it is crucial to gradually reduce the dose of corticosteroids to allow the adrenal glands to resume normal function 1. The tapering schedule may vary depending on the duration of prior steroid use and the patient's clinical status.
Key Considerations
- The dose of hydrocortisone can be adjusted based on the patient's response, with a goal of reaching a physiologic replacement dose (equivalent to prednisone 5 mg daily) 1.
- Patients with known adrenal insufficiency or those who have been on long-term steroids (more than 3 weeks) may require slower tapering, sometimes over months 1.
- During the tapering process, it is essential to monitor for signs of adrenal insufficiency, such as fatigue, weakness, nausea, hypotension, or hypoglycemia 1.
- The gradual reduction is necessary because exogenous corticosteroids suppress the hypothalamic-pituitary-adrenal axis, and abrupt discontinuation can lead to adrenal crisis, which is potentially life-threatening 1.
Tapering Schedule
- Start with hydrocortisone 50-100 mg intravenously every 6-8 hours during the acute phase.
- Transition to oral prednisone once the patient stabilizes.
- Decrease the prednisone dose by 5-10 mg every 3-7 days, depending on the duration of prior steroid use and the patient's clinical status.
- For example, if a patient was on 60 mg of prednisone daily, reduce to 50 mg for 3 days, then 40 mg for 3 days, and so on until reaching a physiologic replacement dose (equivalent to prednisone 5 mg daily) 1.
Education and Monitoring
- Educate patients on stress dosing for sick days, use of emergency injectables, and when to seek medical attention for impending adrenal crisis 1.
- Recommend a medical alert bracelet or necklace for adrenal insufficiency to trigger stress dose corticosteroids by emergency medical personnel 1.
From the FDA Drug Label
If after long-term therapy the drug is to be stopped, it is recommended that it be withdrawn gradually rather than abruptly After a favorable response is noted, the proper maintenance dosage should be determined by decreasing the initial drug dosage in small decrements at appropriate time intervals until the lowest dosage which will maintain an adequate clinical response is reached.
The tapering regimen for stress dose steroids is not explicitly stated, but it is recommended to withdraw the drug gradually rather than abruptly after long-term therapy. The dosage should be decreased in small decrements at appropriate time intervals until the lowest dosage that maintains an adequate clinical response is reached 2, 3. Key points to consider when tapering include:
- Gradual withdrawal
- Small decrements
- Appropriate time intervals
- Maintenance of adequate clinical response It is essential to individualize the tapering regimen based on the patient's response and disease entity being treated.
From the Research
Tapering Regimen for Stress Dose Steroids
The tapering regimen for stress dose steroids, also known as corticosteroids, is a crucial aspect of managing patients who require these medications. The goal of tapering is to minimize the risk of adverse effects while allowing the body to recover from the suppression of the hypothalamic-pituitary-adrenal (HPA) axis 4.
- General Principles:
- Moderate-to-high dose GC therapy may be tapered rapidly to near-physiological doses while watching for features of disease reactivation.
- Once close to the physiological dose, tapering is slower and at longer intervals to allow for recovery of the HPA axis.
- It is essential to use short- or intermediate-acting GC preparations such as hydrocortisone or prednisolone in physiological doses, administered in the morning to mimic the endogenous cortisol rhythm.
Specific Considerations
- Duration of Suppression: The duration of HPA axis suppression is a critical factor in determining the tapering regimen. If the period of suppression has been long, tapering should be slower over a few months to even a year 4.
- Testing of HPA Axis Function: In select cases at high risk of adrenal insufficiency or if symptoms appear during tapering, the decision to further taper and discontinue steroids may be based on testing of HPA axis function using basal and/or stimulated serum cortisol 4.
- Expert Consensus: Expert consensus statements have been generated on oral corticosteroid (OCS) use, tapering, adverse-effect screening, and shared decision-making, which may be used to inform clinical practice 5.
Disease-Specific Considerations
- Asthma: A study on asthma found that steroid tapering is unnecessary in acute asthma; a personal asthma management plan with a reserve course of prednisolone may be more appropriate 6.
- Acute Respiratory Distress Syndrome (ARDS): The efficacy of corticosteroid use in ARDS remains controversial, and a tapering regimen after high-dose corticosteroids is likely to increase ventilator dependency and might aggravate the prognosis of patients with ARDS 7.
- Ulcerative Colitis: Stress dose steroids are administered during the perioperative period to prevent complications of secondary hypoadrenalism, but their administration does not appear to affect adrenal insufficiency outcomes 8.