Steroid tapering guidance

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.

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

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.

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.

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.

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.