Steroid tapering guidance

Acute Oncology Guidelines
NHS Lothian

Abridged from: NHS Lothian Immunotherapy toxicity management guidelines v7.0. S Clive & C Barrie. Last reviewed: 22.11.2021.

Immunotherapy toxicity management - examples of oral prednisolone steroid tapers

  • Steroid dose and duration of taper will differ depending on severity of immunotherapy toxicity and response to initial prednisolone treatment.  
  • Patients should remain under weekly review when being tapered, and the steroid dose should be escalated again if symptoms recur.  
  • If a patient improves rapidly with iv methyl prednisolone then a taper by 5-20mg prednisolone/week (or more rapidly if heavier patient starting at high doses of steroids) over 4-6 weeks may be possible. However if steroid response is slower then a more gentle steroid taper of 5-10mg/week over a few months may be required.  
  • Careful monitoring is required if immunotherapy is re-introduced as there is a high likelihood of recurrence of toxicity or development of a new immune mediated toxicity.  
  • Ensure blood glucose levels are checked with weekly bloods as there is a risk of steroid induced diabetes mellitus.  
  • Prednisolone 25mg tablets are available, should patients have issues with the number of tablets required.

Conversion chart from IV methyl prednisolone to oral prednisolone

Weight IV methyl prednisolone (1mg/kg) Oral prednisolone equivalent (mg)
40 40 50
50 50 60
60 60 75
70 70 85
80 80 100
90 90 110
100 100 125
110 110 135

 

Weight IV methyl prednisolone (2mg/kg) Oral prednisolone equivalent (mg)
40 80 100
50 100 125
60 120 150
70 140 175
80 160 200
90 180 225
100 200 250
110 220 270

Suggested tapering regimen examples

Suggested tapering regimen for oral prednisolone in a 70kg adult initially treated with 1mg/kg methyl prednisolone, assuming rapid initial response and no recurrence of toxicity during taper

Dose Duration (days) Total (days)
70mg 5-7 5-7
60mg 5-7 10-14
50mg 5-7 15-21
40mg 5-7 20-28
30mg 5-7 25-35
20mg 5-7 30-42
10mg 5-7 35-49 (42=6 weeks) and until clinic review
  • In accordance with ASCO guidance steroids should be tapered over at least 4-6 weeks, but longer will often be required.  
  • Review weekly. 
  • Escalate dose to previous dose level if symptoms/ labs indicate worsening toxicity after initial improvement and taper more slowly. 
  • Steroid dose must not exceed 10mg/day if immunotherapy treatment is to be restarted. 
  • As per toxicity specific guidelines  (only accessible when connected to intranet); consider liaising with medical specialities regarding alternative immunosuppressive agents if a prolonged wean looks likely. 

Suggested tapering regimen for oral prednisolone in a 100kg adult initially treated with 1mg/kg methyl prednisolone, assuming rapid initial response to steroids and no recurrence of immunotoxicity during taper 

Dose Duration (days) Total (days)
100mg 5-7 5-7
80mg 5-7 10-14
60mg 5-7 15-21
40mg 5-7 20-28
30mg 5-7 25-35
20mg 5-7 30-42
10mg 5-7 35-49 (42=6 weeks) and until clinic review
  • In accordance with ASCO guidance steroids should be tapered over at least 4-6 weeks, but longer may be required. 
  • Review weekly. 
  • Escalate dose to previous dose level if symptoms/ labs indicate worsening toxicity after initial improvement and taper more slowly. 
  • Steroid dose must not exceed 10mg/day if immunotherapy treatment is to be restarted. 
  • As per toxicity specific guidelines (only accessible when connected to intranet); consider liaising with medical specialities regarding alternative immunosuppressive agents if a prolonged wean looks likely.  

Suggested tapering regimen for oral prednisolone in a 100kg adult initially treated with 2mg/kg methyl prednisolone, assuming rapid initial response to steroids and no recurrence of immunotoxicity during taper 

Dose Duration (days) Total (days)
200mg 5-7 5-7
150mg 5-7 10-14
125mg 5-7 15-21
100mg 5-7 20-28
75mg 5-7 25-35
50mg 5-7 30-42
25mg 5-7 35-49
10mg 5-7 40-56 (42=6 weeks) and until clinic review
  • In accordance with ASCO guidance steroids should be tapered over at least 4-6 weeks, but longer may be required.
  • Review weekly. 
  • Escalate dose to previous dose level if symptoms/ labs indicate worsening toxicity after initial improvement and taper more slowly. 
  • Steroid dose must not exceed 10mg/day if immunotherapy treatment is to be restarted. 
  • As per toxicity specific guidelines (only accessible when connected to intranet) consider liaising with medical specialities regarding alternative immunosuppressive agents if a prolonged wean looks likely.

Editorial Information

Last reviewed: 22/11/2022

Next review date: 22/11/2024

Author(s): Edinburgh Cancer Centre.

Version: 1.0

Approved By: Authorised by CTAC. Refer to Q-Pulse for approval details.

Reviewer name(s): Stewart J.