Corticosteroid Tapering Guidelines

Introduction to Tapering

The Society for Neuro-Oncology recommends that corticosteroids therapy duration should be minimized to prevent long-term sequelae and generally should be tapered rather than abruptly discontinued given the gradual improvement of edema with oncologic therapy and the potential for adrenal insufficiency 1
High-dose corticosteroids (≥16 mg/day) require gradual tapering to prevent adrenal insufficiency 1
Abrupt discontinuation of high-dose corticosteroids can lead to steroid withdrawal syndrome and symptom recurrence 1

A typical tapering schedule for dexamethasone 16mg is: 12mg/day for 2-3 days, then 8mg/day for 2-3 days, then 4mg/day for 2-3 days, followed by 2mg/day for 2-3 days before discontinuation to prevent adrenal insufficiency and symptom recurrence 1
For patients who received dexamethasone 16mg as part of an antiemetic regimen without NK1 antagonist, the recommended taper is: 16mg on day 1, then taper to 8mg daily on days 2-4 3, 4

The tapering speed should be adjusted based on the duration of prior steroid use, with longer use (>3 weeks) requiring slower tapering and brief use (<1 week) allowing for more rapid tapering 1
The tapering speed should also be adjusted based on symptom control, with worsening neurological symptoms during taper requiring a return to the previous effective dose 1
The underlying condition, such as brain metastases with significant edema, may require slower tapering, while post-chemotherapy patients without CNS involvement can often taper more quickly 1

During the tapering process, patients should be monitored for recurrence of initial symptoms, signs of adrenal insufficiency, and steroid withdrawal syndrome 1
Prolonged high-dose steroid use increases the risk of adverse effects, including personality changes, immunosuppression, metabolic derangements, insomnia, and impaired wound healing 2

Too rapid tapering can lead to symptom recurrence and adrenal crisis, while too slow tapering can result in prolonged exposure to steroid side effects, such as hyperglycemia, muscle weakness, and immunosuppression 1