What happens if you abruptly stop taking corticosteroids (cortico-steroid medications)?

Abrupt Discontinuation of Corticosteroids: Risks and Management

Abruptly stopping corticosteroids after prolonged use (>3 weeks) can cause adrenal insufficiency, withdrawal symptoms, and disease relapse, potentially leading to life-threatening consequences. 1, 2

Risks of Abrupt Discontinuation

Adrenal Insufficiency

• Hypothalamic-pituitary-adrenal (HPA) axis suppression occurs in patients receiving >7.5 mg of prednisolone equivalent daily for more than 3 weeks 3
• Symptoms include fatigue, weakness, nausea, vomiting, hypotension, and in severe cases, hypovolemic shock 2, 4
• The prevalence of glucocorticoid-induced adrenal insufficiency might be between 46-100% 24 hours after abrupt withdrawal, and 26-49% after approximately one week 4

Withdrawal Syndrome

• Patients may experience symptoms mimicking adrenal insufficiency despite acceptable cortisol levels 5
• Common symptoms include myalgia, arthralgia, malaise, fatigue, and mood disturbances 1, 6
• This syndrome can persist for months (median duration 10 months in some studies) 5

Disease Relapse

• Rapid discontinuation may cause relapse or worsening of the condition being treated 2
• For inflammatory bowel disease patients, abrupt withdrawal can trigger disease flares that may be difficult to distinguish from withdrawal symptoms 7, 2

Safe Discontinuation Guidelines

When Tapering Is Not Required

• Corticosteroids can be stopped abruptly without tapering if used for less than 3-4 weeks 8, 3
• Low-dose therapy (<7.5 mg prednisolone equivalent daily) for short durations typically doesn't cause significant HPA axis suppression 3

When Tapering Is Required

• Gradual tapering is necessary after prolonged use (>3 weeks) or high doses 3, 1
• A tapering period of at least 1 month is recommended after improvement of the condition 2
• For patients on long-term therapy, tapering should be more gradual (e.g., by 0.5 mg/kg/month) 3

Tapering Approaches

• The tapering schedule should be planned with an organ specialist referral 2
• In inflammatory bowel disease, transitioning to oral dexamethasone under endocrinologist supervision has shown success even in patients with dependency periods of up to 45 years 7
• For patients with atopic dermatitis, tapering is indicated but rebound flares may occur regardless of taper schedule 3

Monitoring During Withdrawal

• Patients should be closely monitored during the tapering process 2, 1
• Morning serum cortisol testing can be used to assess HPA axis recovery in some patients 8
• For patients with repeated low cortisol concentrations despite prolonged physiological dosing, further testing with ACTH stimulation test may be required 8

Special Considerations

• In acute situations for patients on chronic therapy, adequate glucocorticoid replacement is essential and therapy should not be stopped without tapering 3
• Patients with a history of steroid dependency may require longer tapering periods 7
• Patients should be educated about symptoms of withdrawal and instructed to seek medical advice immediately if they develop an acute illness including fever or infection 1, 2

Emergency Management

• If symptoms of adrenal insufficiency develop during tapering, temporary increase in glucocorticoid dose may be necessary 5
• During periods of stress (surgery, trauma, severe illness), patients who have recently discontinued steroids may require reinstitution of therapy 1
• Adrenal insufficiency should always be taken seriously as it can be life-threatening 4

Remember that individual variation in HPA axis function exists, and neither the glucocorticoid dose nor the duration of treatment can reliably predict adrenal function after withdrawal 4. Therefore, a cautious approach to discontinuation is always warranted for patients on prolonged therapy.