What is the best approach to manage steroid withdrawal syndrome?

From the Guidelines

The best approach to manage steroid withdrawal syndrome is through gradual tapering of steroid medications, using the lowest possible dose for the shortest possible duration, and individualizing the taper based on the patient's response to treatment and ability to tolerate steroids. This approach is supported by the American Society of Clinical Oncology (ASCO) guideline update on the management of immune-related adverse events in patients treated with immune checkpoint inhibitor therapy 1.

Key Considerations

• The tapering schedule should be gradual, with reductions of 10-20% every 1-2 weeks, and slower reductions as lower doses are reached.
• Patients should be monitored for symptoms of adrenal insufficiency, such as fatigue, weakness, dizziness, nausea, and hypotension, during the tapering process.
• Supplemental short-acting steroids may be needed during periods of stress or illness.
• Supportive measures, including maintaining adequate hydration, balanced nutrition, regular exercise as tolerated, and electrolyte monitoring, are crucial during the tapering process.

Special Considerations

• Certain patients, such as those with pre-existing conditions like diabetes mellitus or an immune-compromised status, and the elderly, will require special attention and careful monitoring during the tapering process.
• A multidisciplinary approach may be necessary in the management of certain steroid-related complications, and institutional guidelines should be considered in decision-making 1.

Tapering Strategy

• The goal is to allow the hypothalamic-pituitary-adrenal axis to recover function, which may take months after long-term steroid use.
• The recovery time depends on the duration of steroid therapy, with longer use requiring more extended tapering.
• For severe withdrawal symptoms, temporary dose increases followed by slower tapering may be necessary.

From the FDA Drug Label

Drug-induced secondary adrenocortical insufficiency may be minimized by gradual reduction of dosage. The lowest possible dose of corticosteroid should be used to control the condition under treatment, and when reduction in dosage is possible, the reduction should be gradual.

The best approach to manage steroid withdrawal syndrome is to gradually reduce the dosage of the corticosteroid to minimize the risk of secondary adrenocortical insufficiency. This approach should be tailored to each individual patient, taking into account the specific condition being treated and the patient's overall health status 2, 2, 3.

• Gradual reduction is key to preventing withdrawal syndrome.
• The lowest possible dose should be used to control the condition.
• Reduction in dosage should be gradual when possible.

From the Research

Definition and Forms of Steroid Withdrawal Syndrome

• Steroid withdrawal syndrome (SWS) refers to the symptoms that occur when glucocorticoids are rapidly reduced or stopped, including relapse of the disease being treated, symptoms of adrenal insufficiency, or a symptom complex similar to adrenal insufficiency despite acceptable cortisol levels 4.
• There are different forms of SWS, including type I (symptomatic and biochemical evidence of HPA suppression), type II (recrudescence of the disease for which the drug was originally prescribed), type III (dependence upon corticosteroids with demonstrably normal HPA function), and type IV (biochemical evidence of HPA suppression without symptoms) 5.

Management and Treatment of Steroid Withdrawal Syndrome

• The management of SWS usually involves a temporary increase in the dose of glucocorticoid replacement therapy, which can help alleviate symptoms 4.
• A slower glucocorticoid tapering regimen may reduce the risk of development of SWS, and physicians should be aware of this condition to provide appropriate treatment 4.
• For anabolic-androgenic steroid withdrawal, treatment consists of supportive therapy and pharmacotherapy, including medications such as testosterone esters, human chorionic gonadotropin, and antidepressants 6.
• Tapering of SSRI treatment to mitigate withdrawal symptoms can be done using a hyperbolic tapering program, which reduces the dose of the medication in a linear manner to minimize withdrawal symptoms 7.

Implications and Etiology of Steroid Withdrawal Syndrome

• Steroid withdrawal syndrome can produce a broad array of signs and symptoms, including high fever, and can be caused by the rapid reduction or stoppage of glucocorticoids 8.
• The etiology of SWS is not fully understood, but it is thought to result from the development of tolerance to glucocorticoids, and mediators such as interleukin-6, corticotrophin-releasing hormone, and vasopressin may play a role in its development 4.
• The incidence of SWS may increase with the use of lower doses of replacement glucocorticoids, and physicians should be aware of this condition to provide appropriate treatment and management 4.