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12. Prevention and Management of Adverse Events Related
to Steroid Use
12.4 Tapering of steroids
• The length of steroid-taper should occur according to the type and severity of
irAE, the initial steroid dose, and individual patient responses rather than other
prespecified criteria.
• Steroid taper should occur slowly, generally over 4–6 weeks.
• Regular clinical evaluation should occur during steroid tapering as there is a risk of
irAE rebound/recurrence.
• In general, oral steroid tapering is recommended to occur over 4–6 weeks, with a
reduction in prednisone or prednisolone of 10 mg every 3–7 days (as irAE allows)
until the dose is 10 mg/day, then reduce by 5 mg every 3–7 days for patients who
respond quickly to steroids. For those who have received steroids for several weeks,
tapering may be more prolonged.
• In general, for patients that require IV steroids, tapering is recommended to occur over
4 weeks or longer. The initial IV conversion from methylprednisolone if ≥1 mg/kg/day
would be to oral prednisone 1 mg/kg/day at minimum and then taper as above.
• Longer steroid tapers (>4–6 weeks) may be required for complete resolution or to
avoid recurrence/rebound of irAE events.
• Patients should be monitored for the symptoms of adrenal insufficiency after
prolonged exogenous steroids
• Stress doses may be needed in the event of illness, injury, surgery
• Option when ready to drop below 5 mg of prednisone or 0.5 mg of dexamethasone
after a longer course with concern for iatrogenic adrenal insufficiency, is to transition to
hydrocortisone at physiologic dosing (10 mg in the morning, 5 mg in the afternoon).
This allows for faster recovery of the HPA axis because it restores diurnal patterns.
• If indicated to control disease, a simultaneous slow, low dose taper of the long-acting
steroid can be given (for example decreasing by 1 mg prednisone per week).
• HPA axis function can be tested 24 hours from last oral hydrocortisone (skip PM
dose, hold AM dose for labs) — measured AM cortisol and ACTH will reflect
endogenous function. Ambiguous results can be clarified with an ACTH stimulation
test similarly prepared for.
(cont'd)
