Ryan Livingston joined the MJH Life Sciences team in March of 2025, shortly after graduating from TCNJ with a bachelor’s degree in English. He enjoys creative writing, reading, and scuba diving. He can be reached at rlivingston@mjhlifesciences.com.

Mimi Kim, MD | Image Credit: Children’s Hospital Los Angeles

On May 6, 2026, Neurocrine Biosciences announced publication of 2 peer-reviewed expert recommendation papers outlining how clinicians may approach glucocorticoid dose reduction after starting crinecerfont in adults and children with classic 

Indication: classic CAH adjunct therapy  

Update: 2 JCEM expert tapering algorithms published  

Focus: supervised glucocorticoid reduction after initiation

The recommendations are presented separately for pediatric patients aged 4 to 17 years and for adults, reflecting different treatment goals and monitoring considerations across age groups. The publication addresses a practical issue left only partly answered by pivotal trial protocols: how to taper supraphysiologic glucocorticoid doses while maintaining cortisol replacement and monitoring for withdrawal or adrenal insufficiency.

“In children and adolescents with classic congenital adrenal hyperplasia, treatment decisions must carefully balance disease control with normal growth and development,” Mimi Kim, MD, associate professor of clinical pediatrics at Keck School of Medicine, University of Southern California, said in a statement. “These recommendations provide clinicians with a structured, practical approach to glucocorticoid management that helps support growth, bone maturation, and pubertal development as CRENESSITY is incorporated into care.”

What the new crinecerfont glucocorticoid-reduction recommendations include

According to the company announcement, the 2 manuscripts offer algorithm-based guidance derived from phase 3 trial experience and clinician experience in practice. For pediatric patients, the recommendations target glucocorticoid reduction toward the upper end of the physiologic range, cited as 8 to 11 mg/m2/day in hydrocortisone equivalents, with the broader physiologic range listed as 4 to 11 mg/m2/day.1 In adults, the target physiologic range is described as 2 to 14 mg/m2/day in hydrocortisone equivalents.

Both papers emphasize gradual, supervised dose reductions rather than abrupt tapering, with ongoing assessment for symptoms of glucocorticoid withdrawal, adrenal insufficiency, and mineralocorticoid imbalance. Key biomarkers include androstenedione, testosterone, renin, and electrolytes, among others. The papers also note glucocorticoid reduction is not necessarily the goal for every patient; some may already be receiving physiologic replacement and may start crinecerfont primarily for androgen control.

Classic CAH, most commonly due to 21-hydroxylase deficiency, has historically required glucocorticoid regimens that balance cortisol replacement with suppression of excess adrenocorticotropic hormone and adrenal androgen production.3 Endocrine Society guidance has long recognized the tradeoff between controlling hyperandrogenism and avoiding overtreatment with glucocorticoids, particularly in growing children.

How phase 3 CAHtalyst data support the FDA-approved use of crinecerfont

Crinecerfont is an oral corticotropin-releasing factor type 1 receptor antagonist intended to reduce pituitary adrenocorticotropic hormone signaling and thereby decrease adrenal androgen production without adding glucocorticoid exposure. The 

 approved the drug in December 2024 for use with glucocorticoids to control androgens in classic CAH.

The approval was supported by the phase 3 CAHtalyst program, which enrolled 285 patients across pediatric and adult studies. In the pediatric program, 103 participants aged 4 to 17 years first underwent 4 weeks of treatment to assess androgen control, followed by 24 additional weeks evaluating whether individualized glucocorticoid down-titration could be achieved while maintaining or improving androstenedione levels. In the adult study, 182 participants aged 18 to 58 years underwent a similar design, with 20 additional weeks assessing reduction of glucocorticoids into the physiologic range while maintaining or improving androstenedione. Open-label extension phases of both trials are ongoing.

Safety considerations and unanswered questions for real-world implementation

The central safety concern during glucocorticoid reduction in CAH remains underreplacement, including adrenal insufficiency or adrenal crisis. The FDA label for crinecerfont warns of sudden adrenal insufficiency or adrenal crisis if patients receive too little glucocorticoid, and it states that glucocorticoid therapy should be continued during treatment. Common adverse effects listed in labeling include tiredness, headache, decreased appetite, and myalgia in adults, and headache, abdominal pain, fatigue, nasal congestion, and epistaxis in children.

The expert papers may help fill an implementation gap as use expands, but several questions remain. The press release did not report long-term outcome data on growth, bone age normalization, fertility-related measures, cardiometabolic outcomes, or rates of adrenal crises under algorithm-guided tapering. Real-world uptake and consistency of biomarker-based monitoring also remain to be seen. For now, the newly published recommendations add age-specific structure to a treatment area where physiologic glucocorticoid replacement and androgen control have often been difficult to reconcile.

Neurocrine Biosciences. Neurocrine Biosciences announces publication of expert recommendations for glucocorticoid dose reduction after initiating CRENESSITY (crinecerfont) for the treatment of classic congenital adrenal hyperplasia. Published May 06, 2026. Accessed May 06, 2026. 

https://neurocrine.gcs-web.com/news-releases/news-release-details/neurocrine-biosciences-announces-publication-expert

CRENESSITY (crinecerfont) prescribing information. Neurocrine Biosciences. Accessed May 06, 2026. 

https://edge.prnewswire.com/c/link/?t=0&l=en&o=4681537-1&h=2790446935&u=https%3A%2F%2Fc212.net%2Fc%2Flink%2F%3Ft%3D0%26l%3Den%26o%3D4325283-1%26h%3D3091277039%26u%3Dhttp%253A%252F%252Fwww.neurocrine.com%252Fcrenessitypi%26a%3DPrescribing%2BInformation&a=Prescribing+Information

Speiser PW, Arlt W, Auchus RJ, et al. Congenital adrenal hyperplasia due to steroid 21-hydroxylase deficiency: an Endocrine Society clinical practice guideline. 

Articles

Two peer-reviewed expert recommendation papers provide age-specific algorithms for reducing supraphysiologic glucocorticoids after initiating crinecerfont in classic 21-hydroxylase–deficient CAH. Pediatric guidance (4–17 years) prioritizes growth and pubertal development, targeting hydrocortisone-equivalent doses near the upper physiologic range; adult guidance targets physiologic replacement while maintaining androgen suppression. Both advocate slow, supervised tapering with biomarker and symptom monitoring for withdrawal, adrenal insufficiency, and mineralocorticoid imbalance. Evidence draws on CAHtalyst phase 3 experience; long-term outcomes and real-world monitoring consistency remain uncertain. FDA labeling underscores continued glucocorticoid therapy to mitigate adrenal crisis risk.

The new recommendations outline glucocorticoid tapering strategies for adults and children with classic CAH after starting crinecerfont.

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Guidance Published for Glucocorticoid Reduction With Crinecerfont in CAH

Noreen Galaria, MD, is a board-certified and fellowship-trained dermatologist based in the Washington, D.C. area with over 20 years of experience. She is the founder of Inner Glow Vitamins and practices at Galaria Plastic Surgery & Dermatology.

Questions on Internal Photoprotection in Dermatology, With Noreen Galaria, MD

, Noreen Galaria, MD, a board-certified dermatologist, founder of Inner Glow Vitamins, and private practice clinician, discussed emerging approaches to photoprotection alongside practical strategies for physician wellness, reflecting key themes from the American Academy of Dermatology Annual Meeting and the Skin of Color Society (SOCS) Scientific Symposium.

Galaria first highlighted the growing interest in “internal photoprotection,” describing it as a shift toward a more comprehensive, layered approach to sun protection that extends beyond traditional sunscreen use. While sunscreen remains foundational in blocking ultraviolet radiation, she explained that increasing attention is being given to antioxidants that work at different levels within the skin cell. Specifically, she outlined how certain compounds may target distinct cellular components: nicotinamide acting at the nuclear level to support DNA repair and reduce nonmelanoma skin cancer risk, polypodium leucotomos reducing oxidative stress within the cytoplasm, and astaxanthin protecting the cell membrane. This complementary, mechanism-based strategy reflects a broader evolution in dermatology, moving from generalized antioxidant use toward more intentional selection based on cellular targets. Galaria noted that this approach may help address multiple outcomes of sun exposure, including pigmentation, photoaging, and carcinogenesis, particularly as environmental factors such as UV exposure continue to intensify.

The discussion then shifted to physician wellness, where Galaria shared insights from a panel she moderated focused on sustainable self-care practices. She emphasized that burnout remains highly prevalent, but solutions may lie less in large, aspirational changes and more in small, repeatable habits integrated into daily routines. Drawing on concepts such as “habit stacking,” she described how clinicians can attach wellness behaviors—such as brief physical activity, posture resets, or mindfulness exercises—to existing routines, thereby reducing barriers to consistency. This approach, she noted, helps make self-care more accessible, particularly for physicians already experiencing time constraints and fatigue.

A recurring theme in the wellness discussion was the importance of sleep, which Galaria identified as a high-impact yet often overlooked intervention. She highlighted the widespread issue of chronic sleep deprivation among clinicians and suggested practical strategies such as establishing consistent wind-down routines, limiting late-night screen exposure, and incorporating opportunities for recovery sleep when possible.

Overall, this segment underscored a dual focus on innovation and sustainability within dermatology, with Galaria emphasizing both the advancement of science-driven, multi-layered photoprotection strategies and the need for realistic, habit-based approaches to maintaining clinician well-being.

Editor’s note: This summary was made with the help of AI tools.

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Noreen Galaria, MD, highlighted the evolving role of internal photoprotection alongside practical, habit-based strategies to support physician wellness and reduce burnout.

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Safety Considerations for IL-17 Inhibitors in Psoriasis 

This episode, titled ‘Safety Considerations for IL-17 Inhibitors in Psoriasis,’ the expert faculty focuses on the safety profile of IL-17 inhibitors in psoriasis, highlighting both class-wide considerations and differences among individual therapies. The panelists emphasize that modern biologics targeting the IL-17 pathway are generally well tolerated, with favorable safety profiles compared with earlier generations of systemic therapies.

The expert dermatologists discuss how there is an increased risk of mild fungal infections, such as tinea and candidiasis, which is a known class effect related to IL-17 inhibitors. They note that these infections are typically manageable, and often occur early in treatment without recurring in most patients. This safety signal reflects the targeted nature of IL-17 inhibition rather than broad immunosuppression.

The panelists also address the potential association between IL-17 inhibitors and inflammatory bowel disease (IBD), including both exacerbation of preexisting disease and possible new onset. The faculty highlights the importance of screening for personal and family history of IBD and incorporating this information into treatment selection and patient counseling. Emerging insights into mechanistic differences within the IL-17 pathway suggest that variations in cytokine targeting may influence these risks, although this remains an area of ongoing research. The expert faculty reinforces the importance of balancing efficacy with safety while tailoring treatment decisions to individual patient profiles in psoriasis care.

In the next episode, ‘Managing Treatment Failure in Psoriasis,’ panelists examine strategies for managing treatment failure in psoriasis, including differentiating primary and secondary non-response and optimizing therapy. It highlights the importance of patient-centered decision-making and the potential value of initiating treatments early to improve long-term outcomes.

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Strober explains how the arrival of icotrakinra, a first-in-class oral IL-23 receptor blocker, has meaningfully shifted the psoriasis treatment paradigm.

Biologics Versus Oral Small Molecules — Redefining the Psoriasis Treatment Hierarchy 

The treatment of moderate to severe psoriasis has been transformed over the past decade by the development of biologic agents targeting the IL-23/IL-17 axis — a cytokine cascade now well established as central to the pathophysiology of psoriatic inflammation. Agents including risankizumab, guselkumab, bimekizumab, and ixekizumab have demonstrated the capacity to achieve deep skin clearance, with substantial proportions of patients reaching Psoriasis Area and Severity Index (PASI) 90 and PASI 100 responses in pivotal trials and real-world settings. These agents remain among the most efficacious treatments in dermatology across any indication, and their performance ceiling — in terms of both speed and depth of response — currently exceeds that of available oral alternatives. For patients in whom rapid, profound clearance is the primary goal, advanced biologics continue to define the standard of care.

That hierarchy has nonetheless been complicated by the introduction of icotrakinra, a first-in-class oral small molecule that targets the IL-23 receptor directly, blocking the downstream effects of IL-23 signaling without requiring injection. Oral agents have historically occupied a lower tier in psoriasis management — effective at mild to moderate disease burdens but unable to approach the response rates of advanced biologics. Icotrakinra challenges that positioning. Phase 3 trial data demonstrated PASI 90 response rates of approximately two-thirds of patients at week 24, a level of efficacy without precedent for an oral psoriasis therapy and one that meaningfully narrows the gap with injectable IL-23 inhibitors. Icotrakinra's once-daily oral dosing, absence of a requirement for routine laboratory monitoring, and manageable safety profile — including a label notation regarding tuberculosis screening that does not mandate testing in all patients — collectively represent a practical convenience profile that injectable biologics cannot match.

In this video discussion on psoriasis treatment selection, Bruce Strober, MD, PhD, Clinical Professor of Dermatology at Yale University School of Medicine, describes how icotrakinra's arrival has already influenced his prescribing behavior in clinical practice. Drawing on approximately 6 weeks of early real-world experience across multiple patients, Strober characterizes icotrakinra as a therapy that is straightforward to initiate, well tolerated, and capable of producing responses he describes as impressive by oral therapy standards. He positions it not as a replacement for advanced biologics but as a meaningful new option for a specific patient population — those who prefer or require oral administration and for whom the efficacy ceiling of an oral IL-23 receptor blocker is acceptable given their disease severity, lifestyle, and treatment goals. The availability of a once-daily oral agent approaching biologic-level outcomes represents, in his view, a genuine paradigm shift for dermatology — one whose full implications for prescribing patterns are still being defined.

Icotrakinra brings once-daily oral IL‑23 receptor blockade with near‑biologic psoriasis clearance, expanding injection-free options for treatment-seeking patients.

Rapid Response in Psoriasis Treatment

In ‘Rapid Response in Psoriasis Treatment,’ our panel explores the clinical importance of rapid treatment response in psoriasis and how speed of efficacy has become valued in biologic therapy selection. While early treatment paradigms prioritized long-term outcomes over initial response, the faculty discuss how rapid skin clearance is now recognized as both clinically meaningful and impactful for patients. Certain life events, such as social engagements, relationships, or seasonal activities, can heighten the urgency for faster improvement, making speed of response an important consideration in real-world practice.

The panelists highlight that IL-17 inhibitors as a class are generally associated with rapid onset of action, with some agents demonstrating faster response rates than others based on clinical trial and meta-analysis data. However, the discussion emphasizes that differences in onset, while measurable, may not always be clinically significant across all patients. Instead, rapid improvement can serve as an important factor in building patient confidence and strengthening the physician–patient relationship, particularly early in treatment.

They also address practical considerations related to dosing strategies, including induction regimens and injection frequency. While some therapies require more frequent dosing upfront to achieve rapid control, others offer simplified regimens without compromising efficacy. The faculty note that clinicians no longer need to trade off speed for long-term outcomes, as newer therapies can deliver both rapid and sustained disease control. This discussion reinforces the growing role of treatment speed as part of a comprehensive, patient-centered approach to psoriasis management.

Our next episode, ‘Safety Considerations for IL-17 Inhibitors in Psoriasis,’ the expert faculty reviews the safety profile of IL-17 inhibitors in psoriasis, including common class effects such as mild fungal infections and considerations related to inflammatory bowel disease. It emphasizes the importance of individualized risk assessment and patient counseling when selecting targeted therapies.

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