What is the recommended approach for tapering corticosteroids (CS) in patients with corticosteroid insufficiency?

Steroid Tapering in Corticosteroid Insufficiency

In patients with corticosteroid insufficiency (adrenal insufficiency), the goal is not to taper corticosteroids but rather to provide lifelong physiologic replacement therapy with hydrocortisone 15-20 mg daily in divided doses, typically 10-20 mg in the morning and 5-10 mg in early afternoon. 1

Critical Distinction: Replacement vs. Tapering

The question requires clarification of a fundamental concept:

• True corticosteroid insufficiency (primary or secondary adrenal insufficiency) requires permanent replacement therapy, not tapering 1
• Iatrogenic adrenal suppression from exogenous corticosteroid therapy requires careful tapering to allow HPA axis recovery 2, 3

Management of True Corticosteroid Insufficiency

Physiologic Replacement Dosing

• Hydrocortisone is the preferred agent at 15-20 mg daily in divided doses (10-20 mg morning, 5-10 mg early afternoon) to mimic physiologic cortisol rhythm 1
• Single morning dosing may be used, but divided doses better replicate normal diurnal variation 2, 3
• This is lifelong therapy that should never be tapered or discontinued 1

Essential Patient Education

• All patients require education on stress dosing: double the maintenance dose during minor illness for 3 days 1, 2
• Medical alert bracelet or necklace is mandatory to ensure emergency stress-dose corticosteroids by EMS 1
• Patients need injectable emergency hydrocortisone for situations where oral intake is impossible 1

Stress Dosing Protocol

• Minor illness: Double current dose for 3 days 1, 2
• Moderate stress: Hydrocortisone 50 mg IV every 6-8 hours 1
• Severe stress/crisis: Hydrocortisone 50-100 mg IV every 6-8 hours initially 1

Tapering Exogenous Corticosteroids to Assess for Recovery

If the question pertains to tapering therapeutic corticosteroids in a patient who may have developed iatrogenic adrenal insufficiency, the approach differs entirely:

When Tapering Is Appropriate

• Corticosteroid use for other immune-related adverse events (not primary adrenal insufficiency) can cause isolated central adrenal insufficiency 1
• Laboratory confirmation of adrenal insufficiency should not be attempted until high-dose corticosteroid treatment is ready to be discontinued 1

Tapering Protocol for Iatrogenic Suppression

For high-dose therapy (>30 mg/day prednisone equivalent):

• Taper rapidly to 10 mg/day over 4-8 weeks while monitoring for disease flare 2
• Once at 10 mg/day, slow the taper to 1 mg every 4 weeks 2

For physiologic doses (≤10 mg/day):

• Taper by 1 mg every 4 weeks until discontinuation 2
• HPA axis suppression should be anticipated in any patient receiving >7.5 mg daily for >3 weeks 2, 3
• Recovery may take up to 12 months after discontinuation following prolonged high-dose therapy 3

Monitoring During Taper

• Morning cortisol testing can guide cessation once at physiologic doses 4
• If cortisol remains low despite 3 months at maintenance hydrocortisone doses, refer to endocrinology for ACTH stimulation testing 1, 4
• Therapy <3-4 weeks duration can be stopped abruptly without tapering 4, 5

Common Pitfalls to Avoid

• Never start thyroid hormone replacement before corticosteroid replacement in patients with multiple pituitary hormone deficiencies, as this can precipitate adrenal crisis 1
• Do not attempt to measure AM cortisol in patients currently on corticosteroids, as therapeutic steroids interfere with the assay 1
• Hydrocortisone must be held for 24 hours before cortisol testing; other steroids require longer washout 1
• Tapering too quickly leads to disease flare or symptomatic adrenal insufficiency 2
• Failing to provide stress-dosing education puts patients at risk for adrenal crisis during intercurrent illness 1, 3

Special Consideration: Immune Checkpoint Inhibitor-Related Hypophysitis

For patients with checkpoint inhibitor-induced hypophysitis causing secondary adrenal insufficiency:

• Grade 1-2: Consider holding immunotherapy until stabilized on replacement hormones 1
• Grade 3-4: Hold immunotherapy and hospitalize for IV stress-dose steroids initially, then transition to oral maintenance 1
• Pulse-dose corticosteroids (prednisone 1-2 mg/kg/day) may be used for significant pituitary swelling or optic chiasm compression, tapered over 1-2 weeks to physiologic maintenance 1
• Once transitioned to physiologic replacement (≤5 mg prednisone equivalent), this becomes permanent therapy 1