When to taper corticosteroids (steroids)?

Steroid Tapering Guidelines

Steroids should be tapered rather than stopped abruptly when used for more than 14 days to prevent adrenal insufficiency, with longer and more gradual tapering required for longer courses of treatment. 1

Risk Factors for Adrenal Insufficiency

• Duration of steroid therapy is the most important factor:
  • Less than 14 days: Generally safe to stop abruptly
  • 14 days to 3 weeks: Tapering recommended
  • More than 3 weeks: Tapering required 1, 2
• Higher doses increase risk (especially >7.5 mg prednisone daily)
• Cumulative dose matters (>3000 mg prednisolone equivalent increases risk)
• Evening dosing causes more HPA axis suppression than morning dosing 3

Tapering Recommendations Based on Duration of Therapy

Short-term therapy (less than 3 weeks)

• Can be stopped abruptly without tapering 2
• For asthma exacerbations: 40-60 mg prednisone for 5-10 days with no taper needed 1, 4

Intermediate-term therapy (3 weeks to 3 months)

• Taper over 2-4 weeks 1
• Reduce to physiologic dose (5-7.5 mg prednisone) relatively quickly
• Then taper more gradually to allow HPA axis recovery

Long-term therapy (more than 3 months)

• Taper very gradually over 4-6 weeks or longer (up to several months) 1
• For high-dose therapy (>20 mg prednisone daily), taper even more slowly
• Initial reduction can be faster (e.g., 10% every 1-2 weeks)
• Once at physiologic dose (5-7.5 mg), slow to 1 mg decrements every 2-4 weeks

Condition-Specific Tapering Protocols

Immune Checkpoint Inhibitor Toxicity

• Taper over 4-6 weeks after symptoms improve to grade 1 5, 1

Lupus Nephritis

• Maintain therapy for at least 1 year before tapering after complete remission 5, 1
• Avoid rapid steroid taper (especially aiming to discontinue by 6 months) as this increases relapse risk 5

Primary Adrenal Insufficiency

• For major surgery: Double oral dose for 24-48 hours after recovery, then taper to normal dose 5
• For minor surgery: Double oral dose for 24 hours, then return to normal dose 5

Practical Tapering Approach

1. Initial phase: Reduce by larger decrements (e.g., 5-10 mg) until reaching near-physiological dose (7.5 mg prednisone)
2. Later phase: Reduce by smaller decrements (1-2.5 mg) with longer intervals between dose reductions
3. Final phase: Consider alternate-day therapy to minimize HPA axis suppression 3

Monitoring During Tapering

• Watch for signs of:
  • Disease recurrence/flare
  • Adrenal insufficiency (fatigue, weakness, nausea, hypotension)
• Educate patients about adrenal insufficiency symptoms 1
• Provide steroid alert card or medical alert bracelet 1
• Schedule follow-up 3 months after discontinuation 1

Special Considerations

• Morning dosing is preferred to mimic natural cortisol rhythm and minimize HPA suppression 3
• Alternate-day therapy may reduce side effects while maintaining therapeutic benefit 3
• Patients may need stress-dose steroids during illness or surgery for up to 12 months after discontinuation 3

Common Pitfalls to Avoid

1. Tapering too quickly in long-term users
2. Failing to recognize symptoms of adrenal insufficiency during tapering
3. Not providing stress-dose instructions for patients recently off steroids
4. Overlooking the need for slower tapering in patients with underlying autoimmune disease
5. Not educating patients about the risks of abrupt discontinuation

Remember that HPA axis recovery takes longer if the period of suppression has been long, so tapering should be slower in these cases 6. All patients on exogenous steroids should be advised about the need for appropriate increases in steroid doses during acute illness or surgery 6.