TABLE 5

Approach to glucocorticoid taper in patients with glucocorticoid-induced adrenal insufficiency and after surgery for Cushing syndrome

Average daily prednisone dose
> 40 mg/day: decrease by 10 mg weekly until 40 mg daily
20–40 mg/day: decrease by 5 mg weekly until 20 mg daily
10–20 mg/day: decrease by 1–2.5 mg weekly until 10 mg daily
5–10 mg/day: decrease by 1 mg weekly until < 5 mg daily
< 5 mg/day: switch to equivalent dose of hydrocortisone (eg, 10 mg in the morning and 5 mg in the early afternoon); hold hydrocortisone for 24 hours and retest HPAA
Testing for HPAA recovery
If patient has been on prednisone 5 mg/day, switch to equivalent dose of hydrocortisone, wait for 2–4 weeks, and hold hydrocortisone for 24 hours before testing

Check 8 am serum cortisol:
 If < 10 μg/dL,a continue current dose of hydrocortisone and retest in 4–8 weeks
 If ≥ 10 μg/dL, perform 250-μg corticotropin stimulation test:

  • If suboptimal (cortisol peak < 12.6 μg/dL at 30 minutes and 60 minutes), consider stopping daily glucocorticoid replacement if patient has no withdrawal symptoms, but continue the sick-day rule (using stress-dose glucocorticoid) until repeating corticotropin stimulation test

  • If optimal (peak cortisol ≥ 12.6 μg/dL), stop glucocorticoid if patient is comfortable


 If 8 am serum cortisol ≥ 12.6 μg/dL, consider stopping glucocorticoid if patient is ready in terms of withdrawal symptoms, or performing 250-μg corticotropin stimulation test or tapering glucocorticoid dose

Frequency of testing:

  • If the results of tests are abnormal, recheck every 2–3 months

  • If no recovery within 1 year, reassess every 3–6 months

Things to consider

  • If glucocorticoid withdrawal syndrome develops at any point, increase the glucocorticoid dose to the most recent dose on which the patient did not have glucocorticoid withdrawal syndrome; consider decrements every other week rather than weekly

  • If patient is on dexamethasone, consider switching to prednisone

  • If patient is on twice-daily prednisone dosing, consider switching to equivalent dose of prednisone in the morning once daily

  • ↵a Values per the Elecsys Cortisol II assay.

    HPAA = hypothalamic-pituitary-adrenal axis

    Based in part on information in reference 81.