Oral Corticosteroid Tapering
NICE CKS Corticosteroids – oral. Last revised: Jul 2025.
NICE guideline [NG243] Adrenal insufficiency: identification and management. 1.9 Managing glucocorticoid withdrawal to prevent adrenal insufficiency. Published: Aug 2024.
Why Oral Corticosteroids Needs Tapering
Prolonged systemic corticosteroid therapy suppresses endogenous cortisol production through negative feedback on the hypothalamic–pituitary–adrenal axis:
- Exogenous glucocorticoids (e.g. oral prednisolone) reduce ACTH secretion
- This leads to reduced adrenal cortisol synthesis
- Sudden withdrawal may result in inadequate cortisol availability, particularly during physiological stress
This can cause:
- Adrenal insufficiency
- Adrenal crisis in severe cases
See the Adrenal Insufficiency (Hypoadrenalism) article for more information.
Tapering is required for systemic corticosteroids, which includes oral, IV, IM routes.
In contrast, most locally administered corticosteroids (e.g. topical, inhaled, intranasal, intra-articular corticosteroids) do NOT require tapering, as systemic absorption is minimal and clinically significant HPA axis suppression is unlikely when used at standard doses.
What is Corticosteroid Tapering
Corticosteroid tapering refers to the gradual, stepwise reduction in corticosteroid dose over time, rather than abrupt cessation, following a period of systemic steroid therapy.
Aims of corticosteroid tapering:
- Allow recovery of the hypothalamic–pituitary–adrenal axis (for endogenous ACTH secretion to recover and resume endogenous cortisol production)
- Prevent adrenal insufficiency
- Reduce the risk of disease flare or rebound inflammation
Who Requires Oral Corticosteroid Tapering
Tapering (gradual withdrawal) should be considered in those whose disease is unlikely to relapse AND meet ANY of the following:
- Received corticosteroid treatment for >3-4 weeks
- Received >40 mg of prednisolone (or equivalent) daily for >1 week
- Recently received repeated courses of corticosteroids (esp. for >3 weeks) (a common scenario is acute asthma exacerbation)
- Have been taking repeated evening doses of corticosteroids
- Taken a short course of corticosteroids within 1 year of stopping long-term treatment
If none of the above applies, oral corticosteroids may be stopped abruptly in those whose disease is unlikely to relapse.
Tapering Regimen
A typical oral glucocorticoid tapering regimen follows the 2 main phases below:
| Phase 1 | Rapidly reduce the steroid dose to daily physiological dose
Physiological dose in >16 y/o:
Physiological dose in <16 y/o: hydrocortisone 8 mg/m2 |
| Phase 2 | Once the patient in on a daily physiological dose, taper more gradually by alternate-day spacing (keeping the same daily doses but increasing the dosing interval):
|
Note: Although NICE CKS and NICE guidance recommended the alternate-day dose spacing as corticosteroid tapering regimen, this approach is used less commonly in clinical practice.
It is more common to achieve tapering through small, incremental daily dose reductions.
In patients who have been taking oral glucocorticoids for >12 weeks, consider an even slower dose-tapering regimen (than what is outlined in the phase 2 row).