withdrawal of steroid therapy

Last edited 07/2021 and last reviewed 07/2021

Three scenarios present commonly in clinical practice:

• after long term treatment - where gradual withdrawal of treatment is indicated
• after short courses of treatment - where abrupt withdrawal may be indicated
• short-term cessation for surgery

Where there has been chronic therapy then seek expert advice.

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

• 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) (2)
    • a pass response to these tests indicates adequate function of the axis and GCs can be safely withdrawn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 (2)
  • 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.

Note that these treatment recommendations should only be used as a guide due to considerable variability between individuals.

Reference:

• Current Problems in Pharmacovigilance (1998), 24, 7.
• 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.