When to Taper Steroids in Addison's Disease
In Addison's disease, you do NOT taper maintenance steroid replacement therapy—patients require lifelong physiologic replacement of hydrocortisone 15-25 mg daily divided into 2-3 doses plus fludrocortisone 0.05-0.2 mg daily. 1, 2, 3 Tapering only applies when returning from stress-dose steroids back to maintenance levels after acute illness, surgery, or adrenal crisis.
Understanding the Core Principle
Addison's disease represents complete adrenal failure requiring permanent hormone replacement—this is substitution therapy, not pharmacologic treatment that can be discontinued. 1, 4 The confusion about "tapering" arises because patients temporarily receive supraphysiologic doses during stress, which must then be reduced back to maintenance levels.
When Tapering IS Appropriate: Returning from Stress Doses to Maintenance
Post-Acute Illness or Adrenal Crisis
- Continue parenteral hydrocortisone 100 mg IV/IM every 6 hours until the patient can eat and drink, then give double the normal oral maintenance dose for 24-48 hours, then return to standard maintenance dosing. 1, 2, 5
- This represents a rapid taper over 1-3 days when recovery is uncomplicated. 5
Post-Major Surgery with Long Recovery
- Administer 100 mg hydrocortisone IM before anesthesia, continue 100 mg IM every 6 hours until able to eat and drink, then double oral dose for 48+ hours, then gradually reduce to normal maintenance dose. 1, 2
- The total tapering period from stress dose to maintenance typically spans 3-5 days. 1, 5
Post-Major Surgery with Rapid Recovery
- Give 100 mg hydrocortisone IM before anesthesia, continue 100 mg IM every 6 hours for 24-48 hours, then double oral dose for 24-48 hours, then return to normal maintenance. 1, 2
- This represents a 2-4 day taper back to baseline. 1
Post-Minor Surgery or Procedures
- Administer 100 mg hydrocortisone IM before the procedure, then double oral dose for 24 hours, then return to normal maintenance dose. 1, 2
- This is the most rapid taper, completed within 24-48 hours. 1, 5
Post-Delivery (Vaginal or Cesarean)
- Give 100 mg hydrocortisone IM at onset of labor (repeat every 6 hours if needed), then double oral dose for 24-48 hours after delivery, then return to normal maintenance. 1, 2, 5
After Febrile Illness or Minor Stress
- When patients have doubled their maintenance dose during illness, continue the doubled dose for 24-48 hours after stress resolves, then return directly to normal maintenance. 2, 5
- No gradual taper is needed—simply resume the usual 15-25 mg daily regimen. 2
Critical Timing Considerations
Restart Fludrocortisone During Taper
- When hydrocortisone dose falls below 50 mg/day during tapering, restart fludrocortisone 0.05-0.1 mg daily, as higher hydrocortisone doses provide sufficient mineralocorticoid effect. 5, 3
- This is often forgotten and can lead to hypotension and electrolyte disturbances. 5
Monitor for Under-Replacement During Taper
- Watch for lethargy, fatigue, weakness, nausea, vomiting, poor appetite, weight loss, hypotension, hyponatremia, and hyperkalemia. 2, 5
- These indicate the taper is too rapid or the patient needs to remain at a higher dose longer. 5
Avoid Over-Replacement
- Signs include weight gain, insomnia, peripheral edema, and hypertension. 2, 5
- If these develop, the taper should proceed more quickly back to maintenance. 2
What Maintenance Dosing Looks Like (The Target After Tapering)
Standard Regimens
- Hydrocortisone 15-25 mg daily divided into 2-3 doses, with the largest dose upon awakening (typically 10 mg at 7 AM, 5 mg at noon, 2.5-5 mg at 4 PM for three-dose regimen). 2, 5
- Two-dose alternative: 15 mg at 7 AM plus 5 mg at noon, or 10 mg at 7 AM plus 10 mg at noon. 5
- Fludrocortisone 0.05-0.2 mg once daily. 2, 3
Monitoring Maintenance Adequacy
- Clinical assessment is the primary tool—plasma ACTH and serum cortisol are not useful for dose adjustment. 2
- Ask about daily energy patterns, mental concentration, daytime somnolence, and whether there are energy dips during the day. 2, 5
- Normal skin pigmentation and blood pressure indicate adequate replacement. 2
Common Pitfalls to Avoid
Never Taper Below Physiologic Replacement
- Unlike pharmacologic steroid therapy for inflammatory conditions, Addison's patients cannot have steroids "tapered off"—they require lifelong maintenance. 1, 2, 4
- Attempting to discontinue or reduce below physiologic doses will precipitate adrenal crisis. 5
Tapering Too Rapidly Precipitates Crisis
- Adrenal crisis is life-threatening and can occur if stress doses are reduced too quickly before the acute stressor has fully resolved. 5
- When in doubt, maintain doubled doses for an additional 24-48 hours. 1, 2
Failure to Educate on Sick Day Rules
- All patients must know to double or triple their maintenance dose during febrile illness, infections, or minor procedures, and to seek emergency care for vomiting/diarrhea preventing oral intake. 2, 5
- Provide emergency injectable hydrocortisone (100 mg IM) and train a companion in its use. 2, 5
- Medical alert identification is mandatory. 2, 5
Stopping Fludrocortisone During High-Dose Hydrocortisone
- While on hydrocortisone ≥50 mg/day, fludrocortisone can be temporarily held, but must be restarted as doses taper below this threshold. 5
- Forgetting to restart fludrocortisone causes salt-wasting and hypotension. 5
Special Populations
Immune-Related Adrenal Insufficiency (Checkpoint Inhibitors)
- For Grade 2 symptoms, taper stress-dose corticosteroids down to maintenance over 5-10 days. 5
- For Grade 3-4 symptoms, taper over 7-14 days after discharge. 5
- 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. 5
Pediatric Patients
- After major surgery, once enteral intake is established, give double the normal dose for 48 hours, then reduce to standard doses (6-10 mg/m² body surface area daily). 5, 6