What is the safest way to taper steroids (corticosteroids)?

How to Taper Steroids

For short courses (<3 weeks) at low-moderate doses, tapering is unnecessary and steroids can be stopped abruptly, but for courses longer than 3 weeks or doses above 7.5 mg/day prednisone equivalent, gradual tapering is essential to prevent adrenal insufficiency. 1, 2

When Tapering is Required

• Tapering is mandatory for any patient receiving more than 7.5 mg prednisone equivalent daily for more than 3 weeks, as HPA axis suppression should be anticipated in these circumstances 1, 2
• For courses of 5-10 days (such as asthma exacerbations), no taper is needed and steroids can be stopped abruptly 3
• The critical threshold is 3 weeks of therapy—beyond this duration, tapering becomes necessary regardless of dose 1, 2

General Tapering Framework

High-Dose Phase (>30 mg/day to 10 mg/day)

• Taper rapidly from high doses to 10 mg/day within 4-8 weeks, as this initial phase primarily addresses disease control rather than HPA axis suppression 1, 4
• Reduce by 5-10 mg per week until reaching 10 mg/day 1, 4
• Monitor closely for disease flare during this phase with visits every 4-8 weeks 1

Medium-Dose Phase (10 mg/day to 5 mg/day)

• Slow the taper significantly once approaching physiological doses 4, 5
• Reduce by 2.5 mg every 2-4 weeks until reaching 5 mg/day 4
• This slower pace allows for HPA axis recovery while minimizing disease reactivation risk 5

Low-Dose Phase (<5 mg/day to discontinuation)

• Taper by 1 mg every 4 weeks until complete discontinuation 1, 4
• Alternative approach: Use 1.25 mg decrements with alternate-day schedules (e.g., alternating 5 mg and 3.75 mg) if 1 mg tablets unavailable 1, 4
• This is the most critical phase for preventing adrenal insufficiency 5

Disease-Specific Modifications

Polymyalgia Rheumatica

• Initial dose: 12.5-25 mg/day, taper to 10 mg/day within 4-8 weeks, then reduce by 1 mg every 4 weeks 1, 4

Inflammatory Myopathies

• Start at 60-80 mg/day, taper by 10 mg every 2 weeks to 30 mg/day, then 5 mg every 2 weeks to 20 mg/day, then 2.5 mg every 2 weeks 4

Asthma Exacerbations

• Use 40-60 mg/day for 5-10 days with no taper required for these short courses 3
• Expert consensus supports attempting tapering in all patients on maintenance oral steroids for chronic asthma 6

Autoimmune Conditions with Steroid-Sparing Agents

• When azathioprine or other steroid-sparing agents are established (after 2-3 months), more aggressive tapering is safe: reduce by 5 mg weekly to 10 mg/day, then 2.5 mg every 2-4 weeks 4

Managing Relapse During Tapering

• If disease flare occurs, immediately return to the pre-relapse dose and maintain for 4-8 weeks before attempting a slower taper 1, 4
• Consider adding steroid-sparing agents (methotrexate, azathioprine, mycophenolate) rather than maintaining high steroid doses if multiple relapses occur 1, 4
• For patients with repeated relapses, indefinite low-dose maintenance (2.5-7.5 mg/day) is acceptable 4

Monitoring Requirements

• Monitor for both disease activity and adrenal insufficiency symptoms: fatigue, weakness, nausea, vomiting, abdominal pain, hypotension, electrolyte disturbances 1
• Follow-up visits every 4-8 weeks in the first year, then every 8-12 weeks in the second year 1
• For disease-specific monitoring (e.g., liver enzymes in autoimmune hepatitis), check monthly during tapering 4

Stress Dosing During and After Tapering

• All patients tapering steroids require supplemental glucocorticoids during acute illness or physiologic stress 4, 5
• For minor illness: double the current prednisone dose for 3 days 4
• For moderate stress: hydrocortisone 50 mg twice daily for 3 days 4
• For severe stress/surgery: hydrocortisone 50 mg three times daily 4
• This requirement persists up to 12 months after discontinuation in patients who received prolonged therapy 4, 7

Critical Pitfalls to Avoid

• Tapering too quickly is the most common error and leads to disease flare or symptomatic adrenal insufficiency 4
• The 5 mg weekly reductions appropriate for short courses are inappropriate after prolonged therapy 4
• Failing to educate patients about stress dosing and signs of adrenal insufficiency 4, 5
• Not providing a medical alert card or bracelet for patients at risk of adrenal crisis 4
• Attempting to taper below physiological doses without ensuring adequate time for HPA axis recovery 5

Special Considerations

• Use single morning dosing to minimize HPA axis suppression, except for prominent night pain on low doses 4
• Elderly patients and those with diabetes, osteoporosis, or glaucoma require more cautious tapering due to increased adverse effect risk 1
• The longer the duration of suppression, the slower the required taper—recovery may take months to a year after prolonged high-dose therapy 5