# Steroid taper after immunotherapy side effects, with Pneumocystis prophylaxis and adrenal checks

Source: https://onco.cc/protocols/irae-steroid-taper-and-pjp/  
OnCo record `irae-steroid-taper-and-pjp` (Protocol). Data CC BY-NC 4.0, attribute "Data from OnCo (onco.cc)"; commercial use needs a licence.

## TL;DR

Steroids for an immunotherapy side effect are reduced slowly, usually over at least 4 to 6 weeks, because stopping too fast can bring it back. A month or more of higher-dose steroids weakens defences against Pneumocystis pneumonia, so a preventive antibiotic (usually co-trimoxazole) is often given. Your body's own steroid production may need checking before the last tablets stop.

## Summary

Steroids are the first-line treatment for most irAEs, and their own harms (hyperglycaemia, mood change, insomnia, gastritis, weight gain, osteoporosis and opportunistic infection including Pneumocystis pneumonia) need counselling (SITC 2021, LE: 1). ASCO 2021 (abstract): taper over at least 4 to 6 weeks. SITC tapers over 4 to 6 weeks for hepatitis, pneumonitis and myocarditis, but within 4 weeks for colitis (LE: 1).

Pneumocystis prophylaxis: ASCO/IDSA 2018 recommends it for regimens carrying more than 3.5% risk, for example 20 mg prednisone equivalent or more daily for a month or longer. ECIL-5 (haematological patients) lists more than 4 weeks of corticosteroids as a main indication and makes trimethoprim/sulfamethoxazole the drug of choice, with pentamidine, atovaquone and dapsone second-line.

Adrenal axis: doses equivalent to 7.5 mg prednisolone or more for over 3 weeks can suppress the adrenal glands, so ESE 2022 advises at least a morning cortisol (with ACTH, and a Synacthen test if needed) before stopping. The 2024 ESE/Endocrine Society guideline on glucocorticoid-induced adrenal insufficiency tapers faster in the supraphysiological range and more slowly at physiological doses.

## Fields

- Kind: Protocol
- Last checked: 2026-11-11
- Also known as: irAE steroid taper; corticosteroid taper for immune-related adverse events; PJP prophylaxis on steroids; PCP prophylaxis immunotherapy; co-trimoxazole prophylaxis on steroids; steroid weaning after immunotherapy toxicity
- Tags: protocol; irae; infection-prevention

## Connected records

- protocols: [Checkpoint inhibitor hypophysitis and adrenal insufficiency: emergency treatment, replacement and steroid emergency card](https://onco.cc/protocols/irae-hypophysitis-adrenal/), [Immune-mediated hepatitis from checkpoint inhibitors, by grade](https://onco.cc/protocols/irae-hepatitis/), [Immune-related diarrhoea and colitis from checkpoint inhibitors, by grade](https://onco.cc/protocols/irae-colitis/), [Immune-related pneumonitis from checkpoint inhibitors, by grade](https://onco.cc/protocols/irae-pneumonitis/), [Restarting a checkpoint inhibitor after an immune-related side effect](https://onco.cc/protocols/irae-rechallenge/)
- ideas: [Treat immunotherapy side-effects without wiping out the response](https://onco.cc/ideas/idea-bio2-steroid-sparing-irae/)
- technologies: [Immune checkpoint inhibitors](https://onco.cc/technologies/checkpoint-inhibitor/)
- drugs: [Atezolizumab](https://onco.cc/drugs/atezolizumab/), [Avelumab](https://onco.cc/drugs/avelumab/), [Cemiplimab](https://onco.cc/drugs/cemiplimab/), [Dostarlimab](https://onco.cc/drugs/dostarlimab/), [Durvalumab](https://onco.cc/drugs/durvalumab/), [Hydrocortisone](https://onco.cc/drugs/hydrocortisone/), [Ipilimumab](https://onco.cc/drugs/ipilimumab/), [Methylprednisolone](https://onco.cc/drugs/methylprednisolone/), [Nivolumab](https://onco.cc/drugs/nivolumab/), [Pembrolizumab](https://onco.cc/drugs/pembrolizumab/), [Prednisone](https://onco.cc/drugs/prednisone/), [Tremelimumab](https://onco.cc/drugs/tremelimumab/)
- institutions: [American Society of Clinical Oncology (ASCO)](https://onco.cc/institutions/asco/), [European Society for Medical Oncology (ESMO)](https://onco.cc/institutions/esmo/), [Society for Immunotherapy of Cancer](https://onco.cc/institutions/sitc/)
- terms: [Immune-related adverse events (irAEs)](https://onco.cc/terms/irae/)
- key papers: [ASCO 2021 guideline: how to recognise and manage the immune-related side effects of checkpoint inhibitors](https://onco.cc/key-papers/paper-asco-irae-guideline-jco-2021/)

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