What are the risks of stopping prednisone (corticosteroid) abruptly?

Risks of Abruptly Stopping Prednisone

Abruptly discontinuing prednisone therapy can cause adrenal insufficiency, which may be life-threatening, especially after prolonged use (>3 weeks) or high doses. 1, 2

Adrenal Suppression Risk

• 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 1
• Prolonged corticosteroid use causes the adrenal glands to reduce or stop natural cortisol production, leading to dependency on exogenous steroids 2
• Adrenal insufficiency occurred in 48.3% of patients on long-term prednisone therapy for systemic inflammatory disorders in one study 3
• The risk of adrenal insufficiency is related to both duration and cumulative dose of steroid treatment 3

Consequences of Abrupt Discontinuation

Adrenal Crisis

• May present with severe hypotension, shock, electrolyte abnormalities, and can be fatal if not promptly treated 2
• Symptoms include fatigue, weakness, dizziness, nausea, vomiting, abdominal pain, and hypotension 1, 2
• Acute hospital admissions for adrenal crises have been documented in patients with adrenal insufficiency after steroid discontinuation 4

Disease Relapse or Flare

• Rapid discontinuation may cause relapse or worsening of the condition being treated 1
• In inflammatory bowel disease, abrupt withdrawal has been associated with disease flares 5
• Studies show higher rates of relapse in patients who discontinue treatment abruptly compared to those who taper 5

Steroid Withdrawal Syndrome

• Following prolonged therapy, withdrawal of corticosteroids may result in symptoms including myalgia, arthralgia, and malaise 2
• Psychiatric symptoms including mood swings, anxiety, and depression may occur 5

Risk Factors for Severe Withdrawal

• Duration of therapy >3 weeks 1, 2
• Daily doses exceeding 7.5 mg prednisolone equivalent 1
• Higher cumulative doses 3
• Longer duration of treatment 3
• Evening dosing (which causes more HPA axis suppression than morning dosing) 2

Safe Discontinuation Guidelines

• If prednisone has been used for less than 3 weeks at low-moderate doses, abrupt discontinuation may be possible without significant risk 1
• For longer courses (>3 weeks), a gradual taper is strongly recommended 1, 2
• FDA labeling specifically warns: "Patients should be warned not to discontinue the use of corticosteroids abruptly or without medical supervision" 2
• The optimal taper schedule depends on duration of therapy, dose, and underlying condition 1

Monitoring During Withdrawal

• Patients should be monitored for signs of adrenal insufficiency during tapering 1
• Symptoms requiring immediate medical attention include severe fatigue, weakness, dizziness, hypotension, or electrolyte disturbances 2
• In some conditions, laboratory monitoring may be needed (e.g., cortisol levels, ACTH stimulation test) 5
• Some patients may require stress-dose steroids during illness or surgery for up to 12 months after discontinuation 2

Special Considerations

• Recovery of normal adrenal function may take months to years after steroid discontinuation 1, 3
• Some patients (18% in one study) still showed adrenal suppression 24 weeks after discontinuing prednisone 6
• In patients with polymyalgia rheumatica or giant cell arteritis, adrenal insufficiency can mimic disease flare, causing diagnostic confusion 4
• Patients with adrenal insufficiency may require hydrocortisone replacement therapy even 2 years after discontinuing prednisone 4

Clinical Approach to Discontinuation

• For chronic therapy, taper by approximately 0.5 mg/kg/month 1
• For patients on physiologic doses (5-7.5 mg prednisone daily), consider slower tapers of 1-2.5 mg decrements every 1-2 weeks 1, 2
• Higher-risk patients may benefit from endocrinology consultation and ACTH stimulation testing before complete discontinuation 4, 3
• Patient education about symptoms of adrenal insufficiency is essential 2