What is the proper protocol for tapering steroids (corticosteroids) in a patient?

How to Taper Steroids

When tapering corticosteroids, the duration and rate depend critically on the duration of prior therapy: steroids used for less than 3-4 weeks can be stopped abruptly without tapering, while prolonged use (>3-4 weeks) requires gradual tapering over at least 1 month to prevent adrenal insufficiency and withdrawal symptoms. 1, 2

Duration-Based Tapering Strategy

Short-Term Use (<3-4 Weeks)

• Abrupt discontinuation is safe for patients who received corticosteroids for less than 3-4 weeks, as HPA axis suppression is unlikely 2
• For uncomplicated recovery from acute illness or adrenal crisis, reduce to double the usual maintenance dose for 24-48 hours, then return to normal maintenance dosing over 1-3 days 3

Prolonged Use (>3-4 Weeks)

• Gradual tapering over at least 1 month is mandatory to avoid adrenal insufficiency and potential adrenal crisis 1, 4
• The reduction should be done in small increments at appropriate intervals until the lowest dose that maintains adequate clinical response is reached 4
• Too rapid tapering precipitates adrenal crisis, which can be life-threatening 3

Specific Tapering Protocols by Clinical Context

Post-Surgical Tapering

• After major surgery: Continue hydrocortisone 100 mg IV/IM every 6 hours until able to eat and drink, then give double the normal oral dose for 48 hours before returning to maintenance 3
• After minor surgery: Give double the normal oral dose for 24-48 hours postoperatively, then return to normal daily dosing 3

Immune-Related Adverse Events (irAEs)

• For Grade 2 symptoms: Taper stress-dose corticosteroids down to maintenance over 5-10 days 3
• For Grade 3-4 symptoms: Taper stress-dose corticosteroids down to maintenance over 7-14 days after discharge 3
• When tapering from prednisone 1-2 mg/kg/day, taper over 1-2 weeks down to physiologic maintenance equivalent to hydrocortisone 15-20 mg daily in divided doses 3

High-Dose Dexamethasone

• From 50 mg dexamethasone: Reduce by approximately 5-10 mg every 1-3 days over 7-14 days until complete discontinuation 5
• Standard protocol: 50mg (days 1-2) → 40mg (days 3-4) → 30mg (days 5-6) → 20mg (days 7-8) → 10mg (days 9-10) → 5mg (days 11-12) → 2.5mg (days 13-14), then discontinue 5

Target Maintenance Dosing

Physiologic Replacement

• Hydrocortisone 15-25 mg daily in divided doses is the standard physiologic replacement 3, 4
• Recommended regimens:
  • Three-dose: 10 mg at 7:00 AM + 5 mg at 12:00 PM + 2.5-5 mg at 4:00 PM 3
  • Two-dose: 15 mg at 7:00 AM + 5 mg at 12:00 PM 3
• Morning administration (before 9 AM) is essential to minimize HPA axis suppression and approximate physiologic cortisol rhythm 6

Alternative Agents

• Prednisone: 4-5 mg daily as alternative to hydrocortisone 3
• Cortisone acetate: 25-37.5 mg daily in divided doses 4

Critical Monitoring During Tapering

Signs of Adrenal Insufficiency (Under-Replacement)

• Watch for: Fatigue, weakness, nausea, vomiting, poor appetite, weight loss, hypotension, and electrolyte disturbances 3, 4
• Hyponatremia is present in 90% of newly diagnosed adrenal insufficiency cases 4
• Hyperkalemia occurs in only ~50% of cases, so its absence does not rule out adrenal insufficiency 4

Signs of Over-Replacement

• Weight gain, insomnia, peripheral edema, hypertension 3
• Regular assessment of body weight, blood pressure, and serum glucose is needed 3

Clinical Assessment

• Question patients about daily energy levels, "get up and go," mental concentration, and daytime somnolence 3
• Ask about low points or dips in energy during the day 3

Critical Pitfalls to Avoid

Never Delay Treatment for Testing

• Treatment of suspected acute adrenal insufficiency should NEVER be delayed for diagnostic procedures 4
• If clinically unstable with suspected adrenal crisis, give IV hydrocortisone 100 mg immediately plus 0.9% saline infusion 4

Avoid Abrupt Withdrawal

• Abrupt withdrawal after prolonged therapy can cause adrenal crisis, exacerbation of underlying disease, or steroid withdrawal syndrome 4, 7, 8
• A too rapid decrease in dose may cause relapse or worsening of adverse effects 1

Stress Dosing Education is Mandatory

• All patients require education on stress dosing for sick days, use of emergency steroid injectables, and when to seek medical attention 3
• Patients must wear medical alert identification for adrenal insufficiency 3, 4
• Provide emergency injectable hydrocortisone and train a companion in its use 3

HPA Axis Suppression Persists

• HPA axis suppression may persist for 9-12 months after discontinuation of supraphysiological doses given for longer than 2 weeks 7
• Hormone therapy should be reinstituted during any stressful situation occurring during that period 3

Perioperative Management

• All patients on glucocorticoid therapy for longer than 1 month who will undergo surgery need perioperative management with adequate glucocorticoid replacement 3
• Endocrine consultation is required prior to surgery or any procedure for stress-dose planning 3, 4

Special Considerations

Steroid Withdrawal Syndrome

• Some patients experience symptoms similar to adrenal insufficiency despite acceptable cortisol levels—this is steroid withdrawal syndrome 9, 8
• This syndrome is self-limiting (median duration 10 months) and responds to temporary increase in glucocorticoid dose 9
• A slower tapering regimen may reduce the risk of developing steroid withdrawal syndrome 9

Alternate-Day Therapy

• For long-term maintenance, consider alternate-day therapy with short-acting corticosteroids (prednisone, prednisolone, hydrocortisone, methylprednisolone) 6
• Dexamethasone and betamethasone are NOT recommended for alternate-day therapy due to prolonged HPA suppression 6
• Administer twice the usual daily dose every other morning to minimize HPA suppression while maintaining therapeutic benefit 6

Drug Interactions

• Medications that increase hydrocortisone requirements: anti-epileptics, antituberculosis drugs, antifungal medications, etomidate, topiramate 4
• Grapefruit juice and liquorice decrease hydrocortisone requirements and should be avoided 4

When to Test HPA Axis Recovery

• For patients on prolonged glucocorticoids, morning serum cortisol testing can assess HPA axis recovery after tapering to physiologic doses 2
• Do not attempt diagnostic testing while patient is still on supraphysiological doses—this will yield false-positive results 4
• Consider ACTH stimulation testing if repeated low cortisol concentrations persist despite prolonged period at physiologic dose 2