where gradual withdrawal of steroid treatment is indicated

Last edited 10/2023 and last reviewed 10/2023

• in general, patients taking any steroid dose for less than 2 weeks are not likely to develop hypothalamic-pituitary-adrenal axis (HPAA) suppression and can stop therapy suddenly without tapering (1)
  • possible exception to this is the patient who receives frequent "short" steroid courses e.g. in asthma
    
    
• do not taper down glucocorticoids if the treatment course is <2 weeks. The risk of HPAA axis suppression in such cases is low, and glucocorticoids can be discontinued abruptly (2)
  • if treatment is prolonged beyond 2 weeks, the risk of HPAA suppression increases

If glucocorticoid therapy > 2 weeks or frequent "short" steroid courses then seek expert advice.

Where there has been chronic therapy, the objective is to rapidly reduce the therapeutic dose to a physiological level (equivalent to 7.5mg/d prednisolone) e.g. by reducing 2.5mg every 3-4 days over a few weeks, and then proceed with slower withdrawal in order to permit the HPAA to recover (1)

• after the initial reduction to physiological levels, doses should be reduced by 1mg/d of prednisolone or equivalent every 2-4 weeks depending upon patient's general condition, until the medication is discontinued
  • as an alternative, after the initial reduction to 5-7.5mg of prednisolone, the clinician can switch the patient to HC 20mg/d and reduce by 2.5mg/d every week until the dose of 10mg/d is achieved
  • after 2-3 months on the same dose, the HPAA function should be assessed through a Corticotropin (ACTH-Synachten) test or through an Insulin Tolerance test (ITT)
    • a pass response to these tests indicates adequate function of the axis and GCs can be safely withdrawn
    • if the axis has not fully recovered, treatment should be continued and the axis function should be reassessed
      
      

• irrespectively of the tapering regimen used, if GC withdrawal syndrome, adrenal insufficiency's symptomatology, or exacerbation of the underlying disease appears, the dose being given at the time should be elevated or maintained for a longer period of time
  
  

• in the absence of evidence of HPAA full recovery in patients who have been treated with GCs for prolonged periods (1)
  • supplementation equivalent to 100-150mg of HC is recommended during situations of severe stress such as major surgery, fractures, severe systemic infections, major burns, etc.

Reference:

• Nicolaides NC, Pavlaki AN, Maria Alexandra MA, et al. Glucocorticoid Therapy and Adrenal Suppression. [Updated 2018 Oct 19]. In: Feingold KR, Anawalt B, Boyce A, et al., editors. Endotext [Internet]. South Dartmouth (MA): MDText.com, Inc.; 2000-.
• Prete A, Bancos I. Glucocorticoid induced adrenal insufficiency. BMJ. 2021 Jul 12;374:n1380.