How to taper a corticosteroid (Cris) dose?

Corticosteroid Dose Tapering

When tapering corticosteroids, reduce the dose gradually over at least 1 month from the time of clinical improvement to prevent relapse and adrenal insufficiency, with the specific tapering schedule depending on the indication, severity, and duration of treatment. 1

General Tapering Principles

The fundamental rule is to taper slowly once symptoms improve to grade 1 or baseline, as too rapid tapering causes relapse of the underlying condition or precipitates adrenal crisis. 1, 2

Key Considerations:

• Continue corticosteroids at the therapeutic dose until clinical improvement occurs, then initiate tapering 1
• Taper over at least 1 month minimum to avoid relapse or worsening of adverse effects 1
• Monitor closely for signs of adrenal insufficiency during tapering: fatigue, weakness, nausea, vomiting, abdominal pain, hypotension, and electrolyte disturbances 2
• Avoid abrupt withdrawal - this is critical regardless of indication 3

Context-Specific Tapering Protocols

For CAR T-Cell Therapy Complications (ICANS/CRS):

Rapidly taper steroids as clinically appropriate once symptoms improve to grade 1, with the following approach: 1

• Grade 2 ICANS: After dexamethasone 10 mg IV every 6-12 hours, rapidly taper when symptoms improve to grade 1 1
• Grade 3-4 ICANS: After methylprednisolone 1,000 mg IV daily for 3 days, continue until improvement to grade 1, then taper as clinically appropriate 1

For Immune Checkpoint Inhibitor Toxicities:

Initiate gradual dose decrease over at least 1 month from the time of improvement, with the tapering scheme planned with the organ specialist 1

• Too rapid tapering may cause relapse or worsening of the immune-related adverse event 1
• Coordinate with the prescribing oncology team for any dose adjustments 1

For Primary Adrenal Insufficiency (Stress Dosing):

After resolution of adrenal crisis or acute illness requiring higher doses: 2

• Taper by reducing to double the usual oral dose for 24-48 hours 2
• Then return to normal maintenance dose 2
• Following major surgery: Continue 100 mg hydrocortisone IM every 6 hours until able to eat/drink, then double oral dose for 48+ hours before returning to maintenance 2

For Septic Shock:

Taper hydrocortisone when vasopressors are no longer required, tapering over several days rather than abrupt cessation to avoid hemodynamic and immunologic rebound 2

For Pemphigus Vulgaris:

Once remission is induced with healing of the majority of lesions: 1

• 50% reduction every 2 weeks initially 1
• Reduce by 5-10 mg of prednisolone weekly in practice 1
• More slowly below 20 mg prednisolone daily 1
• Slower tapering needed in patients with history of repeated relapses 1

For Thyroiditis (Checkpoint Inhibitor-Related):

Standard approach: 4

• 60 mg daily × 4 weeks 4
• 30 mg daily × 4 weeks 4
• 15 mg daily × 2 weeks 4
• 5 mg daily × 1 week (11 weeks total) 4

FDA-Approved Tapering Guidance

The FDA label for prednisone states: 3

• Decrease the initial drug dosage in small increments at appropriate time intervals until the lowest dosage maintaining adequate clinical response is reached 3
• If stopping after long-term therapy, withdraw gradually rather than abruptly 3
• Constant monitoring is needed regarding drug dosage adjustments 3

Alternate Day Therapy Transition:

For patients on long-term daily corticosteroids, consider transitioning to alternate day therapy by: 3

• Triple or even quadruple the daily maintenance dose and administer every other day 3
• Once controlled, attempt to reduce to minimum effective dose 3

Critical Pitfalls to Avoid

Adrenal Crisis Risk:

Tapering too rapidly precipitates adrenal crisis, particularly in patients on prolonged therapy 2, 5

• Recovery time for normal HPA axis activity is variable depending on dose and duration of treatment 3
• Patients remain vulnerable to stressful situations during and after tapering 3

Steroid Withdrawal Syndrome:

Even with acceptable cortisol levels, patients may develop withdrawal symptoms resembling adrenal insufficiency: 5

• This is self-limiting and treated by temporary increase in glucocorticoid dose 5
• Median duration is 10 months (range 6-10 months) 5
• Slower tapering regimens may reduce this risk 5

Disease Relapse:

Premature tapering increases recurrence risk of the underlying condition being treated 4

• Monitor for worsening of pre-existing symptoms during tapering 1
• Be prepared to increase doses during intercurrent illness or stress 2

Monitoring Algorithm During Tapering

At each tapering step, assess: 2

• Clinical symptoms of adrenal insufficiency (fatigue, weakness, nausea, hypotension) 2
• Blood pressure (supine and standing) 2
• Electrolytes (sodium, potassium) 2
• Signs of disease relapse specific to the underlying condition 1

If symptoms worsen or disease flares: 3

• Return to full suppressive dose temporarily 3
• Re-establish control before attempting to taper again 3