When to taper corticosteroids (steroids)?

When to Taper Steroids

Steroids should be tapered rather than stopped abruptly when used for more than 14 days, with longer and more gradual tapering required for longer courses of treatment to allow for hypothalamic-pituitary-adrenal (HPA) axis recovery. 1, 2

Factors Determining Tapering Approach

Duration of Steroid Therapy

• Short-term use (<1 week): No taper needed 3, 4
• 1-3 weeks: Rapid taper over 5-10 days 5
• >3 weeks to 3 months: Gradual taper over 2-4 weeks 1, 5
• >3 months: Slow taper over 4-6 weeks or longer (up to several months) 5, 6

Dose Considerations

• High-dose therapy (>20 mg prednisone daily): Taper more gradually
• Near-physiological doses (<7.5 mg prednisone): Taper very slowly, reducing by 1 mg every 4-8 weeks 5
• Initial tapering: Can reduce dose rapidly until reaching 5-10 mg/day 6
• Final tapering: Slow reduction when approaching physiological doses (5 mg/day) 6

Condition-Specific Tapering Guidelines

Sepsis

• For courses <14 days: May stop abruptly
• For courses >14 days: Taper over several weeks
• Monitor for recurrence of inflammation after discontinuation 1

Immune-Related Adverse Events (irAEs)

• Grade 1-2 irAEs: Taper over 2-4 weeks
• Grade 3-4 irAEs: Taper over 4-6 weeks
• Adrenal insufficiency: Taper to maintenance doses over 5-10 days for moderate symptoms, 7-14 days for severe symptoms 1

Inflammatory/Autoimmune Conditions

• Bullous pemphigoid: Reduce dose 15 days after disease control, with aim to stop treatment 4-12 months after initiation 1
• Myasthenia gravis: Evidence supports rapid tapering with azathioprine is more effective than slow tapering 7

Tapering Strategies

General Approach

1. Initial reduction: Once disease is controlled, reduce by 25-50% of the current dose
2. Middle phase: Reduce by 5-10 mg decrements until reaching 10 mg/day
3. Final phase: Reduce by 1-2.5 mg decrements when below 10 mg/day 5, 6

Practical Considerations

• Morning dosing: Administer in the morning to mimic natural cortisol rhythm 6
• Alternate-day therapy: Consider for long-term maintenance to reduce side effects 2
• Monitoring: Watch for:
  • Disease flare-up
  • Signs of adrenal insufficiency (fatigue, weakness, dizziness, nausea)
  • Withdrawal symptoms (myalgia, arthralgia, malaise) 2

Special Situations

Stress Dosing During Taper

• Patients may need increased doses during acute illness or stress
• For patients on physiological doses: Consider 25 mg hydrocortisone twice daily during stress
• For patients on higher doses: Consider 50 mg hydrocortisone three times daily during stress 5

Warning Signs to Slow Tapering

• Recurrence of original disease symptoms
• Development of adrenal insufficiency symptoms:
  • Fatigue, weakness
  • Orthostatic hypotension
  • Nausea, vomiting
  • Hypoglycemia 2

Patient Education

• Provide steroid alert card/medical alert bracelet
• Warn against abrupt discontinuation
• Educate about signs of adrenal insufficiency
• Instruct on stress dosing during illness 1, 5

Common Pitfalls to Avoid

1. Tapering too quickly when approaching physiological doses
2. Failing to recognize adrenal insufficiency during taper
3. Not providing stress-dose instructions
4. Stopping abruptly after prolonged therapy
5. Not monitoring for disease recurrence after discontinuation 5, 2, 6