How do you taper off hydrocortisone (cortisol replacement therapy)?

Tapering Hydrocortisone: A Practical Guide

When tapering hydrocortisone, gradually reduce the dose over time based on the duration of treatment and clinical response, with the goal of returning to normal physiologic cortisol levels while avoiding adrenal insufficiency. 1

General Principles for Tapering

• For patients on hydrocortisone for less than 3-4 weeks, the medication can be stopped abruptly without tapering as hypothalamic-pituitary-adrenal (HPA) axis suppression is unlikely 2
• For patients on prolonged hydrocortisone therapy (more than 3-4 weeks), gradual tapering is necessary to prevent adrenal insufficiency 2, 3
• The tapering schedule should be individualized based on the underlying condition, dose, and duration of treatment 4
• After a favorable response is noted, determine proper maintenance dosage by decreasing the initial drug dosage in small decrements at appropriate intervals until the lowest effective dose is reached 4

Specific Tapering Recommendations

For Primary Adrenal Insufficiency

• After resolution of an adrenal crisis or acute illness requiring higher doses, taper by reducing to double the usual oral dose for 24-48 hours, then return to normal maintenance dose 1
• Following major surgery with long recovery time, continue 100 mg hydrocortisone IM every 6 hours until able to eat and drink, then double oral dose for 48+ hours before tapering to normal dose 1
• For major surgery with rapid recovery, continue 100 mg hydrocortisone IM every 6 hours for 24-48 hours, then double oral dose for 24-48 hours before tapering to normal dose 1

For Septic Shock

• Taper hydrocortisone when vasopressors are no longer required 1
• For patients treated with hydrocortisone for septic shock, a fixed-duration protocol or clinically guided regimen can be used 1
• Tapering over several days is recommended rather than abrupt cessation to avoid hemodynamic and immunologic rebound effects 1

For Long-term Therapy

• For patients on long-term therapy who need to discontinue, reduce the dose gradually rather than abruptly 4
• Consider reducing by 0.5 mg/kg per month when tapering to minimum effective dose 1
• For ACTH-dependent relative adrenal insufficiency, consider testing for recovery of the HPA axis after 3 months of maintenance therapy 3

Monitoring During Tapering

• Monitor for signs of adrenal insufficiency during tapering: fatigue, weakness, nausea, vomiting, abdominal pain, hypotension, and electrolyte disturbances 1, 3
• For some patients on prolonged glucocorticoids, morning serum cortisol testing can be used to assess HPA axis recovery and guide cessation 2
• Further testing of the HPA axis with an ACTH stimulation test may be required in patients with repeatedly low cortisol concentrations despite a prolonged period at a physiological glucocorticoid dose 2

Special Considerations

• Tapering may need to be slower in patients with a history of repeated relapses of their underlying condition 1
• Patients with adrenal insufficiency should be educated on stress dosing during illness even after tapering to maintenance doses 3
• All patients should be monitored for weight, blood pressure, and serum electrolytes at least annually while on hydrocortisone therapy 3

Common Pitfalls to Avoid

• Tapering too rapidly, which can precipitate adrenal crisis 1, 2
• Failure to increase doses during intercurrent illness or stress 1, 3
• Not providing patients with emergency instructions and injectable steroids 3
• Stopping treatment abruptly after long-term use, which can lead to life-threatening adrenal insufficiency 4, 2

Remember that the goal of tapering is to minimize the risk of adrenal insufficiency while allowing the HPA axis to recover normal function. The tapering schedule should be adjusted based on clinical response and any signs of adrenal insufficiency.