Is tapering necessary when discontinuing steroid (corticosteroid) therapy?

Steroid Tapering When Discontinuing Therapy

Tapering is generally necessary when discontinuing corticosteroid therapy to prevent adrenal insufficiency and withdrawal symptoms, especially after prolonged use (>3 weeks) or high doses. 1, 2

Risk of Adrenal Insufficiency

• Hypothalamic-pituitary-adrenal (HPA) axis suppression should be anticipated in any patient receiving more than 7.5 mg of prednisolone equivalent daily for more than 3 weeks, making tapering necessary 1
• Adrenal insufficiency can occur at varying rates (ranging from 0% to 100%, median 37.4%) following systemic corticosteroid therapy, with risk persisting in approximately 15% of patients even 3 years after withdrawal 3
• Risk of adrenal insufficiency varies by administration route, with highest rates seen in intra-articular (52.2%) administration compared to lower rates with nasal administration (4.2%) 4

Tapering Recommendations by Duration and Dose

Short-term therapy (<3 weeks)

• For short courses (<3 weeks) at low-moderate doses, abrupt discontinuation may be possible without significant risk of adrenal insufficiency 1
• However, even short-term high-dose therapy can cause HPA axis suppression, so caution is warranted 4

Prolonged therapy (>3 weeks)

• Tapering is strongly indicated to decrease risk of adrenal suppression 1
• Patients on prolonged corticosteroids should be warned about possible steroid withdrawal syndrome, including weakness, nausea, and arthralgia 1
• Drug-induced secondary adrenocortical insufficiency may result from too rapid withdrawal and should be minimized by gradual reduction of dosage 2

Disease-Specific Considerations

• Atopic Dermatitis: A taper is indicated to decrease risk of adrenal suppression, though rebound flare of dermatitis upon steroid discontinuation may occur regardless of taper schedule 1
• Rheumatoid Arthritis: In a randomized controlled trial of patients with rheumatoid arthritis on tocilizumab, continuing low-dose prednisone (5 mg/day) provided better disease control than tapering, though two-thirds of patients were able to safely taper their glucocorticoid dose 5
• Inflammatory Bowel Disease: Patients receiving prolonged courses of corticosteroids are at risk of adrenal suppression and should have a tapering course if stopping 1
• Brain Metastases: Corticosteroid therapy duration should be minimized to prevent long-term sequelae and generally should be tapered rather than abruptly discontinued 1

Practical Tapering Approaches

• For patients on chronic medium/high-dose glucocorticoid treatment, tapering should be gradual (e.g., by 0.5 mg/kg/month) 1
• In atopic dermatitis, regardless of the taper schedule, flare of the dermatitis upon steroid discontinuation may be expected 1
• For patients with focal segmental glomerulosclerosis, following complete remission of proteinuria, cyclosporin should be slowly tapered (by 0.5 mg/kg/month) to a minimum effective dose 1

Special Considerations

• In acute situations for patients on chronic medium/high-dose glucocorticoid treatment, adequate glucocorticoid replacement is recommended; glucocorticoid therapy should not be stopped without tapering 1
• Inflammation may recur after discontinuing corticosteroid therapy, especially when stopped abruptly 1
• Patients should be carefully monitored after discontinuing corticosteroids, with potential reinitiation if deterioration occurs 1

Common Pitfalls and Caveats

• Rebound flare and increased disease severity is a commonly observed phenomenon upon discontinuation of systemic steroids, particularly in atopic dermatitis 1
• A pilot study comparing an 8-day course of 40 mg/day prednisone with an 8-day tapering course found no difference in relapse rate or adrenal suppression, but this was a small study with only 15 patients 6
• There is no administration form, dosing, treatment duration, or underlying disease for which adrenal insufficiency can be completely excluded, although higher doses and longer use give the highest risk 4
• Adrenal suppression can occur even with inhaled corticosteroids at lower than previously reported doses 7

In conclusion, tapering corticosteroids is generally necessary when discontinuing therapy, particularly after prolonged use or high doses, to prevent adrenal insufficiency and withdrawal symptoms. The tapering schedule should be individualized based on duration of therapy, dose, underlying condition, and patient response.