Situations in which abrupt withdrawal is appropriate

• 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
• note that BNF guidance states (3):
  • for all corticosteroids (systemic) in adults:
    • "..magnitude and speed of dose reduction in corticosteroid withdrawal should be determined on a case-by-case basis, taking into consideration the underlying condition that is being treated, and individual patient factors such as the likelihood of relapse and the duration of corticosteroid treatment. Gradual withdrawal of systemic corticosteroids should be considered in those whose disease is unlikely to relapse and have: Systemic corticosteroids may be stopped abruptly in those whose disease is unlikely to relapse and who have received treatment for 3 weeks or less and who are not included in the patient groups described above. During corticosteroid withdrawal the dose may be reduced rapidly down to physiological doses (equivalent to prednisolone 7.5 mg daily) and then reduced more slowly. Assessment of the disease may be needed during withdrawal to ensure that relapse does not occur..."
      • received more than 40 mg prednisolone (or equivalent) daily for more than 1 week;
      • been given repeat doses in the evening;
      • received more than 3 weeks' treatment;
      • recently received repeated courses (particularly if taken for longer than 3 weeks);
      • taken a short course within 1 year of stopping long-term therapy;
      • other possible causes of adrenal suppression.
  • the BNF guidance differs from other guidance (1,2) in stating that systemic steroid therapy for up to 3 weeks is safe for abrupt steroid withdrawal whereas the other references suggest that if therapy is more than 2 weeks then the risk of hypothalamic-pituitary-adrenal axis (HPAA) suppression increases

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

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.
• NICE. British National Formulary (BNF) (accessed 4/10/23)