From the Guidelines
A slow steroid taper starting from 80 mg should be tailored to the individual patient's response, but a general approach can be applied, as recommended by the BSR/BHPR 2021 guidelines 1.
Recommended Tapering Regimen
The tapering regimen can be divided into several phases:
- Start with 80 mg daily for 1-4 weeks, as suggested by the BSR 2017 guidelines 1
- Decrease by 10 mg every 2-4 weeks until reaching 40 mg, as recommended by the BSR 2017 guidelines 1
- Slow the taper to 5 mg reductions every 2-4 weeks until reaching 20 mg, as suggested by the BSR/BHPR 2021 guidelines 1
- Below 20 mg, reduce by 2.5 mg every 2-4 weeks until reaching 10 mg, then by 1 mg every 2-4 weeks until complete discontinuation, as recommended by the BSR 2017 guidelines 1
Important Considerations
It is essential to monitor patients for signs of adrenal insufficiency during the taper, including unusual fatigue, dizziness, nausea, or hypotension, as noted in the study by Lundberg et al 1. Patients on long-term steroid therapy (more than 3 weeks) are at higher risk for adrenal suppression and require this careful tapering approach, as highlighted in the study by Bunch et al 1. The medication should be taken in the morning with food to minimize gastrointestinal side effects and sleep disturbances.
Evidence-Based Approach
The recommended tapering regimen is based on the most recent and highest-quality study available, which is the BSR/BHPR 2021 guidelines 1. This approach allows the hypothalamic-pituitary-adrenal axis to recover function progressively, reducing the risk of withdrawal symptoms and adrenal insufficiency. By following this tapering regimen, patients can minimize the risks associated with steroid therapy and improve their overall quality of life.
From the FDA Drug Label
In the treatment of acute exacerbations of multiple sclerosis daily doses of 200 mg of prednisolone for a week followed by 80 mg every other day for 1 month have been shown to be effective. If after long-term therapy the drug is to be stopped, it is recommended that it be withdrawn gradually rather than abruptly The tapering of 80 mg of prednisone should be done gradually to avoid withdrawal symptoms.
- The exact tapering schedule is not specified in the label, but it is recommended to decrease the dose in small increments at appropriate time intervals.
- The goal is to reach the lowest dosage that will maintain an adequate clinical response 2
From the Research
Steroid Tapering Regimens
- The efficacy and safety of steroid tapering regimens have been studied in various contexts, including myasthenia gravis, heart transplantation, and multiple sclerosis relapses 3, 4, 5, 6.
- A slow steroid taper regimen is often recommended, but the optimal tapering schedule is not well established 3, 5.
- A study on myasthenia gravis found that a rapid tapering regimen was feasible, well tolerated, and associated with a good outcome, with a higher proportion of patients achieving minimal manifestation status without prednisone at 12 months 5.
- In contrast, a study on multiple sclerosis relapses found that oral prednisolone tapering after intravenous methylprednisolone did not show superior efficacy compared to placebo, but had a comparable safety and tolerability profile 6.
Tapering Regimen Comparison
- A comparison of corticosteroid tapering regimens in myasthenia gravis found that a rapid tapering regimen allowed for sparing of a mean of 1898 mg of prednisone over 1 year, with no significant difference in serious adverse events 5.
- A study on giant cell arteritis found that rapid tapering of prednisone was associated with a higher frequency of relapse, suggesting that a slower tapering regimen may be more effective in this context 7.