Glucocorticoid Tapering Regimen

Rationale

• possible cortisol deficiency resulting from hypothalamic-pituitary-adrenal axis (HPA) suppression during the period of steroid therapy

Indication for Immediate Cessation

• Immediate cessation or reduction to physiological doses (rather than tapering)
• Steroid-induced acute psychosis that is unresponsive to antipsychotic medications
• Herpesvirus-induced corneal ulceration, which can rapidly lead to perforation of the cornea and possibly permanent blindness

HPA suppression	Criteria	Action
likely	more than 20 mg of prednisone a day for more than three weeks evening/bedtime dose of ≥5 mg of prednisone for more than a few weeks patient who has a Cushingoid appearance	do not need testing to evaluate their HPA function be treated like any patient with secondary adrenal insufficiency
unlikely	any dose of glucocorticoid for less than three weeks alternate-day prednisone at a dose of less than 10 mg (or its equivalent)	gradual reduction in dose do not need to be tested for HPA functional reserve
Intermediate/ uncertain	10 to 20 mg of prednisone per day for more than three weeks less than 10 mg of prednisone (providing that it is not taken as a single bedtime dose) for more than a few weeks

Tapering regimen

Short-term glucocorticoid therapy (up to three weeks), even if at a fairly high dose	stopped and need not be tapered (HPA) suppression due to glucocorticoid use of this duration will not persist and is highly unlikely to have any clinical consequence. proceed more cautiously in a frail or dangerously ill patient
glucocorticoid for a longer time	suggest a regimen which is largely based factors of age, frailty, concomitant illnesses, dangerousness and likelihood of flare of underlying illness, psychological factors, and duration of previous use of glucocorticoids are taken into account aim for a relatively stable decrement of 10 to 20 percent, while accommodating convenience

Example

Current Dose (mg/day)	Reduce by (mg/day)	Duration
> 40	5-10	every 1-2 weeks
20-40	5	every 1-2 weeks
10-20	2.5	every 2-3 weeks
5-10	1	every 2-4 weeks
<5	0.5	every 2-4 weeks
symptoms of cortisol deficiency many patients with rheumatic diseases complain of recurrent symptoms of the underlying disease
Alternate day regimen	generally effective in most rheumatic diseases, patients with rheumatoid arthritis often do not tolerate alternate-day dosing
not major	Use NSAIDS or analgesia	wait 7 to 10 days
If the symptoms do not subside	increase the prednisone dose by 10 to 15%	Maintain for 2-4 weeks
increase in dose not sufficient	double the prednisone dose	Disease flare is allowed to subside Taper is reinstituted at a slower rate or at smaller decrements
life-threatening flares (acute recurrence of lupus nephritis, severe hemolysis, acute polymyositis, or vasculitis)	original, highest dose of steroids should be instituted	Flare is allowed to subside Taper is reinstituted at a slower rate or at smaller decrements
If the symptoms resolve	above tapering regimen can be resumed	Every 2-4 weeks rather than 1-2 weeks

Reference:

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