What happens if you don't taper prednisone (corticosteroid)?

Consequences of Not Tapering Prednisone

Abrupt discontinuation of prednisone can lead to potentially life-threatening adrenal insufficiency, severe rebound inflammation, and withdrawal symptoms that can significantly impact morbidity and mortality. 1

Adrenal Insufficiency

Prednisone and other corticosteroids suppress the hypothalamic-pituitary-adrenal (HPA) axis, which can lead to adrenal insufficiency when discontinued abruptly. This occurs because:

• HPA axis suppression should be anticipated in any patient who has taken more than 7.5mg of prednisolone equivalent daily for more than 3 weeks 2
• During prolonged therapy, the body reduces its natural cortisol production, relying instead on the exogenous corticosteroid
• Without tapering, the adrenal glands cannot resume normal cortisol production quickly enough to meet the body's needs 3

Symptoms of Adrenal Insufficiency

• Fatigue, weakness, dizziness
• Nausea, vomiting, abdominal pain
• Hypotension (potentially severe)
• Hypoglycemia
• Electrolyte abnormalities (particularly hyponatremia)
• In severe cases, adrenal crisis can occur, which is a medical emergency that can be fatal 4

Rebound Inflammation

Abrupt discontinuation can lead to a dramatic worsening of the underlying condition being treated:

• Patients with inflammatory conditions may experience severe flares 5
• For atopic dermatitis patients, significant rebound flaring has been documented, leading to premature discontinuation of clinical trials 5
• In autoimmune hepatitis, abrupt discontinuation can trigger disease exacerbation 5

Withdrawal Syndrome

Even without underlying disease flares, patients may experience a constellation of symptoms known as steroid withdrawal syndrome:

• Generalized muscle and joint pain
• Fatigue
• Headache
• Fever
• Anorexia
• Nausea
• Mood changes including depression, anxiety, and irritability
• Postural hypotension 5, 3

Risk Factors for Severe Consequences

The risk of adverse effects from not tapering prednisone increases with:

1. Duration of therapy - longer courses create greater HPA axis suppression
2. Higher doses - doses above 20mg daily for more than 3 weeks significantly increase risk 2
3. Pre-existing conditions - patients with cirrhosis have higher frequencies of complications (25% vs 8%) 5
4. Time of day - evening doses disrupt the natural cortisol rhythm more than morning doses 2

Proper Tapering Approach

To avoid these complications, a structured tapering schedule is recommended:

• Initial taper: Reduce prednisone from 40mg to 30mg daily for 5-7 days, then to 20mg daily for 5-7 days
• Intermediate taper: Reduce to 15mg daily for 5-7 days, then to 10mg daily for 5-7 days
• Final taper: Reduce to 7.5mg daily for 5-7 days, then to 5mg daily for 5-7 days, and finally to 2.5mg daily for 5-7 days before discontinuation 2

Special Considerations

• Stress situations: Patients who experience significant stress (illness, surgery, trauma) during or after tapering may require temporary increases in corticosteroid dosing 1
• Monitoring: During tapering, patients should be monitored for signs of the underlying condition worsening and for symptoms of adrenal insufficiency 2
• Long-term recovery: Full recovery of the HPA axis may take up to 12 months after discontinuation of therapy 1

Patient Education Points

Patients should be educated about:

• The importance of never stopping prednisone suddenly
• The need to take medication in the morning to mimic natural cortisol rhythm
• Signs and symptoms of adrenal insufficiency to watch for
• The potential need for stress dosing during acute illness or surgery
• The importance of wearing medical alert identification if on long-term therapy 2, 1

By following proper tapering protocols, the serious risks associated with abrupt discontinuation of prednisone can be minimized, improving patient outcomes and quality of life.