What is the recommended approach for tapering steroids in patients with chronic steroid use, particularly those who have been on steroids for more than 3 months?

Steroid Tapering in Chronic Steroid Use (>3 Months)

Patients on steroids for more than 3 months require gradual tapering to prevent adrenal insufficiency, and the risk of hypothalamic-pituitary-adrenal (HPA) axis suppression should be anticipated in anyone receiving >7.5 mg prednisone equivalent daily for >3 weeks. 1, 2

Why Tapering is Essential

Abrupt discontinuation of chronic steroids can cause life-threatening adrenal crisis, disease flare, and steroid withdrawal syndrome. 2

• HPA axis suppression occurs with doses >7.5 mg prednisone equivalent daily for >3 weeks, and this suppression may persist for up to 12 months after discontinuation 1, 2
• Adrenal insufficiency affects approximately 50% of patients tested immediately after withdrawal of medium- or high-dose prednisolone used for long periods 3
• Drug-induced secondary adrenocortical insufficiency can be minimized by gradual dose reduction 2

Practical Tapering Protocol

For Patients on High Doses (>30 mg/day)

Taper by 5 mg weekly until reaching 10 mg/day, then slow the taper significantly. 4

• Reduce to 10 mg/day within 4-8 weeks 4
• Once at 10 mg/day, taper by 2.5 mg every 2-4 weeks 4
• At 5 mg/day and below, reduce by 1 mg every 4 weeks until discontinuation 1, 4

For Patients on Low-Moderate Doses (≤10 mg/day)

Taper by 1 mg every 4 weeks until complete discontinuation. 1, 4

• If 1 mg tablets are unavailable, use alternate-day dosing schedules (e.g., 5 mg/4 mg on alternating days) to achieve gradual reductions 4
• Single daily morning dosing is preferred to minimize adrenal suppression 4

Alternative Approach Using Alternate-Day Schedules

For doses below 10 mg, consider 1.25 mg decrements using alternate-day schedules:

• Example: 10 mg/7.5 mg on alternating days, then 7.5 mg daily, then 7.5 mg/5 mg alternating 4

Critical Monitoring During Tapering

Symptoms of Adrenal Insufficiency to Watch For

Patients must be warned about steroid withdrawal syndrome, which can mimic the underlying disease. 3

Common symptoms include:

• Weakness, fatigue, loss of appetite 3
• Nausea, vomiting, diarrhea, abdominal pain 3
• Myalgia, arthralgia, malaise 2
• Hypotension and electrolyte abnormalities 5

Laboratory Monitoring

Morning cortisol levels should be checked before complete discontinuation. 6, 7

• Morning cortisol <5 µg/dL indicates adrenal suppression 6
• Morning cortisol ≥223.5 nmol/L (approximately 8 µg/dL) has 100% specificity for identifying patients without biochemical adrenal insufficiency 7
• If morning cortisol is 5-10 µg/dL, perform cosyntropin stimulation test (250 µg with cortisol measured at baseline and 60 minutes) 6
• Peak cortisol <500 nmol/L (approximately 18 µg/dL) on stimulation test is diagnostic of adrenal insufficiency 5

Managing Disease Flare During Tapering

If symptoms of the underlying disease recur during tapering, immediately return to the pre-relapse dose and maintain for 4-8 weeks before attempting a slower taper. 4

• Do not continue tapering if disease activity increases 4
• Consider adding steroid-sparing agents if multiple relapses occur 4
• Monitor disease-specific markers (e.g., inflammatory markers, proteinuria) monthly during tapering 4

Stress Dosing Requirements

Patients require supplemental glucocorticoids during acute illness or physiologic stress while tapering and for up to 12 months after discontinuation. 4, 2

Stress Dosing Protocol

• Minor illness (fever, URI): Double the current prednisone dose for 3 days 4
• Moderate stress (gastroenteritis, minor surgery): Hydrocortisone 50 mg twice daily for 3 days 4
• Major stress (severe infection, major surgery): Hydrocortisone 50 mg three times daily or 100 mg IV 4, 5

Patient Education Essentials

All patients must be educated about stress dosing and carry emergency injectable glucocorticoids. 6

• Prescribe hydrocortisone 100 mg intramuscular injection for emergency use 6
• Advise patients to seek immediate medical attention for acute illness with fever or signs of infection 2
• Consider medical alert bracelet for adrenal insufficiency 4, 5
• Patients should inform all healthcare providers they are on or recently discontinued chronic steroids 2

Common Pitfalls to Avoid

The most common error is tapering too quickly, which leads to disease flare or symptomatic adrenal insufficiency. 4

• Never use 5 mg weekly reductions for patients on steroids >3 months—this is only appropriate for short courses 4
• Do not abruptly discontinue steroids without medical supervision 2
• Avoid stopping steroids without checking morning cortisol levels first 7
• Do not assume patients on low doses (<10 mg) are safe from adrenal insufficiency—46% of patients with glomerular disease on chronic steroids developed biochemical AI regardless of dose 7

Special Considerations for Patients on Steroid-Sparing Agents

If azathioprine or other steroid-sparing agents have been established for 2-3 months, tapering can be accelerated. 4

• Reduce prednisone by 5 mg every week until reaching 10 mg/day 4
• Then taper by 2.5 mg every 2-4 weeks once at 10 mg/day 4
• Monitor disease activity markers monthly during accelerated tapering 4
• Ensure steroid-sparing agent dose is adequate (e.g., azathioprine 2 mg/kg/day) before aggressive steroid reduction 4

Bone Health Protection During Tapering

All patients on steroids ≥3 months require calcium, vitamin D, and consideration of bisphosphonate therapy. 3, 2

• Calcium 800-1000 mg daily (dietary or supplement) 3
• Vitamin D 800 IU daily (if deficient, treat with 50,000 IU weekly for 6 weeks initially) 3
• Bisphosphonate therapy should be initiated if bone mineral density T-score is ≤-1.5 or FRAX 10-year risk ≥20% for major osteoporotic fracture 3
• Consider intravenous zoledronic acid annually if malabsorption or GI side effects from oral bisphosphonates 3

Timeline for HPA Axis Recovery

Recovery from adrenal insufficiency takes considerable time and varies by individual. 7

• Mean recovery time is 8.7 ± 4.6 months after complete steroid withdrawal 7
• HPA axis suppression may persist for up to 12 months after discontinuation 2
• Patients with lower post-synacthen cortisol at initial testing take longer to recover 7
• Continue stress dosing precautions for the full 12-month period after discontinuation 2