Should this patient be weaned off steroids if she is improving?

Steroid Tapering for a Patient Showing Improvement

For a patient who is improving on steroid therapy, the steroids should be gradually tapered rather than abruptly discontinued to prevent rebound of symptoms and adrenal insufficiency. 1

Principles of Steroid Tapering

When a patient shows improvement while on steroid therapy, the following approach should be implemented:

For Stable or Improved Disease:

• Decrease the steroid dose to the lowest dose that provides satisfactory symptom relief and disease control 1
• Do not abruptly withdraw steroids, as this can lead to:
  • Adrenal insufficiency
  • Rebound of underlying condition
  • Steroid withdrawal syndrome (myalgia, arthralgia, malaise) 2

Tapering Schedule:

1. For moderate (grade 2) conditions that have improved to grade 1:

   • Wean over 2 weeks
   • Re-escalate if worsening occurs
   • Treatment may be resumed once prednisolone ≤ 10 mg 1

2. For severe (grade 3/4) conditions that have improved to grade 2:

   • Change to oral prednisolone
   • Wean over at least 4 weeks 1
   • For grade 3, rechallenge with immunotherapy only at consultant discretion

Monitoring During Tapering

During the steroid taper, closely monitor for:

• Signs of disease recurrence or flare
• Symptoms of adrenal insufficiency (fatigue, weakness, dizziness, hypotension)
• Electrolyte abnormalities

The FDA label for prednisone specifically warns that "adrenocortical insufficiency may result from too rapid withdrawal of corticosteroids and may be minimized by gradual reduction of dosage." 2

Special Considerations

Immune-Related Adverse Events

For patients on steroids for immune checkpoint inhibitor-related toxicities:

• Once improved to grade 1, taper over at least 4 weeks 1
• For grade 3-4 pneumonitis that has improved, taper over >2 months 1
• Consider prophylactic antibiotics for pneumocystis pneumonia for patients receiving ≥20 mg methylprednisolone or equivalent for ≥4 weeks 1

Risk of Rebound Phenomenon

A case report demonstrated clinical deterioration and rebound pneumonia after discontinuation of dexamethasone in a COVID-19 patient, highlighting the importance of appropriate steroid tapering 3

Contraindications to Rapid Tapering

Avoid rapid tapering in:

• Patients with long-term steroid use (>2 weeks)
• High-dose steroid regimens
• Conditions with high risk of relapse

Conclusion

The evidence strongly supports gradual tapering of steroids in patients showing improvement rather than abrupt discontinuation. This approach minimizes the risk of disease rebound and adrenal insufficiency while allowing for continued disease control at the lowest effective dose.