How to taper oral hydrocortisone (corticosteroid) when initially taken 4 times a day?

Tapering Oral Hydrocortisone from Four-Times-Daily Dosing

When discontinuing hydrocortisone that was initially given four times daily, taper gradually by reducing the dose in small decrements at appropriate time intervals rather than stopping abruptly, with the specific taper duration and rate depending on the original indication and treatment duration. 1

Tapering Strategy Based on Clinical Context

For Immune-Related Adverse Events (Checkpoint Inhibitor Therapy)

Taper stress-dose hydrocortisone down to oral maintenance doses over 5-7 days when transitioning from IV stress dosing (hydrocortisone 50-100 mg Q6-8 hours) to physiologic replacement. 2

• Once stabilized, maintain on physiologic replacement doses of hydrocortisone 15-20 mg in divided doses (typically given 2-3 times daily, not four times daily for maintenance). 2
• If pulse-dose prednisone was used for significant symptoms, taper over 1-2 weeks and transition to physiologic maintenance therapy once down to 5 mg prednisone equivalent. 2

For Inflammatory Conditions (Non-Adrenal Insufficiency)

Taper by decreasing the initial drug dosage in small decrements at appropriate time intervals until the lowest dosage maintaining adequate clinical response is reached. 1

• For immune-related colitis requiring prednisone 1-2 mg/kg/day: taper over 4-6 weeks once improvement occurs, aiming to reach ≤10 mg/day before considering resumption of other therapies. 2
• The FDA label emphasizes that if long-term therapy is being stopped, withdraw gradually rather than abruptly. 1

For Septic Shock or Critical Illness

Taper hydrocortisone when vasopressors are no longer required, tapering over several days rather than abrupt cessation to avoid hemodynamic and immunologic rebound effects. 3

Specific Tapering Protocols

Transitioning from Acute Stress Dosing to Maintenance

For patients with adrenal insufficiency recovering from crisis or acute illness:

• Reduce to double the usual oral maintenance dose for 24-48 hours, then return to normal maintenance dose. 3
• Following major surgery: 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. 3

General Tapering Principles

Monitor for signs of adrenal insufficiency during tapering: fatigue, weakness, nausea, vomiting, abdominal pain, hypotension, and electrolyte disturbances. 3

• Tapering may need to be slower in patients with history of repeated relapses of their underlying condition. 3
• Constant monitoring is needed regarding drug dosage adjustments based on clinical status changes, disease exacerbations, or patient exposure to stressful situations. 1

Critical Pitfalls to Avoid

Tapering too rapidly can precipitate adrenal crisis, particularly in patients who have been on prolonged therapy or high doses. 3

• Failure to increase doses during intercurrent illness or stress during the taper can lead to adrenal insufficiency. 3
• Patients must be educated on stress dosing during illness even after tapering to maintenance doses. 3
• All patients need education on when to seek medical attention for impending adrenal crisis and should have a medical alert bracelet for adrenal insufficiency. 2

Maintenance Dosing After Taper

Once tapered from four-times-daily dosing, physiologic replacement typically uses 15-20 mg hydrocortisone in divided doses (usually 2-3 times daily, not four times daily). 2

• Weight-adjusted dosing decreases interpatient variability and is recommended: body weight is the most important predictor of hydrocortisone clearance. 4
• Thrice-daily dosing before food is optimal for maintenance therapy. 4