Is it necessary to prescribe a steroid taper after two weeks of high-dose prednisone (60 mg daily)?

Interesting question. Not being an endocrinologist, I don't have the expertise to advise but the reference below makes the statement that even short-term steroids can be an issue. I suspect that if you have to stop abruptly from 60 mg daily for 2 weeks, it would probably be fine in most instances but if I had an option, I still think I'd taper (Pelewicz and Miskiewicz, PMID 33923971).

"Moreover, recent studies have proven that short-term (<4 weeks), as well as low-dose (<5 mg prednisone equivalent per day) GC treatment can also suppress the hypothalamic–pituitary–adrenal axis."

The simple answer to this is "no" but I think for a bigger picture of when to taper and how to taper, here is a recent link by Brett et al., NEJM Journal Watch 2024.

The answer is no, with some caveats. I recommend reviewing the paper by Cardenas et al., PMID 36545644.

Of course, I agree with my colleagues.

But... for excellent reviews I must add the most recent open-access European Society of Endocrinology and Endocrine Society Joint Clinical Guidelines for Diagnosis and therapy of glucocorticoid-induced adrenal insufficiency by Beuschlein et al., PMID 38714321.

@Dr. First Last with RheumNow also did an excellent summary that is a very fast, practical read on these guidelines: 

Good Clinical Practice Recommendations on Glucocorticoid Withdrawal and Adrenal Insufficiency

My 2 cents: Granted I take care of AYA cancer patients who are otherwise healthy.

I see a lot of high-dose steroid use/recommendations with long tapers for treating immune-related side effects from CPI drugs.

Besides the many side effects we are all aware of, steroids are associated with early relapse and earlier death.

• The impact of corticosteroid use during anti-PD1 treatment.
• Della Corte & Morgillo, PMID 30964127

I suggest looking at steroid-sparing agents whenever possible, many of which ALSO have anti-cancer activity, depending on the type of cancer.

For example, depending on which organ system is involved: Tocilizumab (anti-IL-6 - we have an AACR poster showing how it helps shrink cancer), Everolimus (many cancers respond to mTORs), Cyclophosphamide (low dose), Methotrexate (low dose), 6MP, Rituximab.

I encourage thinking about these alternatives that may also help fight the cancer, and allow restarting or concurrent use of the CPI.

As far as cold turkey stop or not, why not drop to a physiologic dose of hydrocortisone as a matter of routine (or maybe 2x physiologic) to prevent an adrenal crisis - a relatively small and easy-to-deal-with problem when you are fighting cancer?

The first 3 problems in my patients are (1) cancer (2) cancer (3) cancer then we mitigate side effects.

I have appreciated the helpful responses to the question. One question I cant seem to find an answer to with all the great resources cited is how long does it take to suppress the HPA axis? I suspect it might be based on dose and formulation of CS. I have used the data from years ago that suggested beyond 2 weeks was the point at which a taper of steroids is needed.

Based on this perception, I have used 10-14 days bursts of prednisone in doses of 5-10 mg to help control disease flare while I modify my primary immunomodulator. I then stop the prednisone without tapering. I have done this for many years without apparent problems.

On the other hand, If I put someone on 60 mg of prednisone per day it is because I think that the patient has a life or organ-threatening inflammatory disease and that they will need long-term therapy. Most of these patients will need steroid support at some dose until another immunosuppressant can take over the work and prednisone can be tapered.

The only scenario that I can imagine is where an abrupt stoppage of high-dose prednisone is in someone suspected of GCA and another explanation for symptoms is rapidly identified that does not require steroids. (I have seen this a few times in my career). Stopping high-dose steroids with a quick step-down taper seems warranted.