What is the recommended tapering schedule for prednisone (corticosteroid) in a patient with infectious glomerulonephritis (inflammation of the glomeruli in the kidneys)?

From the Guidelines

For infective glomerulonephritis, a tapering regimen of prednisone should be individualized, but typically starts with a high dose, such as 1 mg/kg up to 60 mg, and then rapidly reduced to 15 mg at 12 weeks, as recommended by the BSR/BHPR 2021 guidelines [BSR/BHPR 2021@]. When tapering prednisone, it is essential to monitor for signs of disease recurrence, such as increased proteinuria, rising creatinine, or worsening edema, as well as adrenal insufficiency symptoms, including fatigue, weakness, dizziness, nausea, and hypotension [@1@]. The tapering schedule should be tailored to the individual patient based on disease severity, duration of therapy, and patient response. Some studies suggest that a more rapid reduction in glucocorticoids may be as effective but safer than the standard corticosteroid tapering regimen, as shown in the PEXIVAS trial [@1@]. Key considerations for tapering include:

• Starting with a high dose of prednisone, such as 1 mg/kg up to 60 mg, and then rapidly reducing it
• Monitoring for disease recurrence and adrenal insufficiency symptoms
• Individualizing the tapering schedule based on disease severity, duration of therapy, and patient response
• Continuing concurrent antimicrobial therapy as prescribed to address the underlying infection. It is crucial to prioritize the patient's morbidity, mortality, and quality of life when making decisions about tapering prednisone, and to base these decisions on the most recent and highest-quality evidence available, such as the 2021 guidelines from the BSR/BHPR [@1

From the FDA Drug Label

If after long-term therapy the drug is to be stopped, it is recommended that it be withdrawn gradually rather than abruptly

• The FDA drug label recommends gradual withdrawal of prednisone after long-term therapy.
• For infective glomerulonephritis, the label does not provide specific guidance on tapering prednisone.
• However, it suggests that the dosage should be individualized and adjusted based on the patient's response and clinical status.
• The label also recommends constant monitoring of the patient's condition and adjusting the dosage as needed.
• In general, the goal is to find the lowest effective dose that maintains an adequate clinical response.
• It is essential to consult a doctor before stopping or tapering prednisone, as abrupt withdrawal can have adverse effects 1.

From the Research

Tapering Steroid Prednisone on Infective Glomerulonephritis

• The use of prednisone in treating infective glomerulonephritis is a topic of interest, with various studies examining its efficacy and safety 2, 3.
• A study published in 2023 found that prednisone combined with mycophenolate mofetil was effective for the treatment of immunoglobulin A nephropathy with moderate-to-severe renal dysfunction 2.
• However, another study published in 2021 found that there was no significant impact of steroid use on outcome in patients with infection-related glomerulonephritis 3.
• The tapering of steroid prednisone is not explicitly discussed in the provided studies, but it is mentioned that patients in the glucocorticoid therapy group were administered prednisone 0.5-0.8 mg/(kg·d-1) for 4-8 weeks, which was reduced by 5 mg every two weeks until the maintenance dose was reached 2.
• It is essential to note that the treatment approach for infective glomerulonephritis can vary depending on the underlying cause and severity of the disease, and steroids may be used in certain cases to reduce inflammation and prevent further kidney damage 4, 5.

Treatment Approaches

• The treatment of infective glomerulonephritis can include supportive care, renin-angiotensin-aldosterone system blockade, immunomodulatory therapy, and renal transplant 4.
• A review published in 2021 discussed the clinical and pathologic findings associated with infection-related glomerulonephritides, highlighting the importance of accurate diagnosis and treatment approach 5.
• Another study published in 2012 reported the case of a woman with idiopathic membranous glomerulonephritis unresponsive to the Ponticelli regimen and treated with adrenocorticotropic hormone in association with azathioprine, showing a dramatic decrease of proteinuria and beneficial effects on lipid profile 6.

Outcome and Prognosis

• The prognosis of infective glomerulonephritis is largely dependent on the underlying cause of the disease and can vary from a self-limited course to chronic kidney disease 4.
• A study published in 2021 found that persistent proteinuria, hematuria, and hypertension at 6 months were seen in 11.1,7.4, and 3.7% of patients with infection-related glomerulonephritis, respectively 3.
• The same study found that there was a significant negative correlation between renal recovery and history of diabetes, interstitial fibrosis and tubular atrophy, glomerulosclerosis, and IgA deposits 3.