From the Guidelines
Steroids should be stopped if a patient experiences severe adverse effects or if the benefits of continued steroid use no longer outweigh the risks, and should always be tapered rather than abruptly discontinued to prevent adrenal insufficiency, as recommended by the British Society of Gastroenterology consensus guidelines on the management of inflammatory bowel disease in adults 1.
Indications to Stop Steroids
The decision to stop steroids depends on various factors, including the presence of severe adverse effects, the duration and dose of steroid therapy, and the patient's overall condition.
- Severe adverse effects such as uncontrolled hypertension, hyperglycemia requiring insulin, psychosis, severe infection, avascular necrosis, or significant osteoporosis with fractures are indications to stop steroids.
- Prolonged steroid use is associated with numerous side effects, including increased infection risk, osteoporosis, suppression of the hypothalamic-pituitary-adrenal axis, diabetes, weight gain, and cardiovascular disease, as noted in the British Society of Gastroenterology consensus guidelines on the management of inflammatory bowel disease in adults 1.
Tapering Steroids
Tapering steroids is crucial to prevent adrenal insufficiency, and the tapering schedule depends on the duration and dose of steroid therapy, with longer and higher-dose regimens requiring more gradual tapering over weeks to months 1.
- For example, prednisone might be reduced by 5-10mg every 1-2 weeks until reaching 20mg daily, then by 2.5mg every 1-2 weeks until discontinuation.
- During tapering, patients should be monitored for signs of disease flare or adrenal insufficiency such as fatigue, weakness, hypotension, nausea, or vomiting.
Monitoring and Management
- Steroids work by suppressing the hypothalamic-pituitary-adrenal axis, which can take months to recover after prolonged steroid use.
- Abrupt discontinuation can lead to adrenal crisis, a potentially life-threatening condition characterized by severe hypotension, electrolyte abnormalities, and shock.
- The Society for Immunotherapy of Cancer (SITC) toxicity management working group recommends tapering corticosteroids over 4-8 weeks or until grade 1 symptoms are achieved 1.
From the FDA Drug Label
Patients should be warned not to discontinue the use of corticosteroids abruptly or without medical supervision When used at higher than recommended doses or in rare individuals at recommended doses, systemic corticosteroid effects such as hypercorticism and adrenal suppression may appear. If such changes occur, the dosage of Fluticasone Propionate Nasal Spray, USP, should be discontinued slowly consistent with accepted procedures for discontinuing oral corticosteroid therapy The indications to stop steroids include:
- Adrenal insufficiency: Patients should be warned not to discontinue the use of corticosteroids abruptly or without medical supervision as prolonged use may cause adrenal insufficiency.
- Systemic corticosteroid effects: If systemic corticosteroid effects such as hypercorticism and adrenal suppression occur, the dosage should be discontinued slowly.
- Infection: If a localized infection of the nose and pharynx with Candida develops, treatment with Fluticasone Propionate Nasal Spray, USP should be discontinued.
- Worsening of symptoms: If symptoms do not improve or if the condition worsens, the patient should contact the physician. 2 2 3
From the Research
Indications to Stop Steroids
The decision to stop steroid therapy is crucial to minimize adverse effects and prevent complications such as adrenal insufficiency. The following points highlight the indications to stop steroids:
- Duration and dose of steroid therapy: Steroid therapy should be used at the lowest effective dose for the shortest possible time to minimize adverse effects 4.
- Suppression of the hypothalamic-pituitary-adrenal (HPA) axis: GC therapy may cause suppression of the HPA axis, and abrupt discontinuation can predispose patients to features of GC-induced adrenal insufficiency 4, 5.
- Tapering of steroid therapy: The practice of tapering GC therapy allows for recovery of the HPA axis while minimizing the risk of a disease flare-up or symptoms of adrenal insufficiency 4, 6.
- Monitoring for adrenal insufficiency: Patients on exogenous steroids should be advised about the need for an appropriate increase in GC doses during acute medical or surgical illness, and should carry a steroid alert card to avoid adrenal crisis 4, 5.
- Individualized tapering approach: Experts agree that OCS tapering should be attempted in all patients with asthma receiving maintenance OCS therapy, with personalization of tapering rhythm and speed 6.
- Recognition of individual adverse effects: The importance of recognizing individual adverse effects, such as adrenal insufficiency, is established, and a unified approach to assessment is recommended 6, 7, 5.
- High-dose inhaled corticosteroid use: ICS at high doses appear to be a significant independent risk factor for adrenal insufficiency, and physicians prescribing ICS at such dosages should be sensitive to the signs and symptoms of adrenal insufficiency in their patients 8.