What is the proper protocol for tapering prednisone (corticosteroid)?

From the Guidelines

Prednisone should be tapered by reducing the dose by 5 mg every week until 10 mg/day are achieved, and then further reduction by 2.5 mg/week can be considered up to 5 mg daily, as recommended by the most recent and highest quality study 1. When tapering prednisone, it is essential to do so under medical supervision to minimize the risk of withdrawal symptoms and adrenal insufficiency.

• The tapering schedule may vary depending on the starting dose and the condition being treated.
• For example, if a patient is taking 20 mg of prednisone daily, the dose can be reduced by 5 mg every week until 10 mg/day are achieved, and then further reduction by 2.5 mg/week can be considered up to 5 mg daily.
• Another study 1 recommends reducing the oral dose gradually to a dose of 10 mg/day prednisone equivalent within 4–8 weeks, and then tapering by 1 mg/4 weeks until discontinuation, given that remission is maintained. However, the study from 2010 1 provides a more specific and detailed tapering schedule, which is preferred in this case. It is crucial to monitor patients for signs of their original condition returning or withdrawal symptoms during the taper and to contact their healthcare provider if they experience concerning symptoms.
• Patients on long-term corticosteroid treatment should also be monitored for bone disease by baseline and annual bone mineral densitometry of the lumbar spine and hip 1.
• The combination regimen of prednisone and azathioprine is associated with a lower occurrence of corticosteroid-related side effects than the higher dose prednisone regimen, and it is the preferred treatment 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If after long-term therapy the drug is to be stopped, it is recommended that it be withdrawn gradually rather than abruptly Adrenocortical insufficiency may result from too rapid withdrawal of corticosteroids and may be minimized by gradual reduction of dosage This type of relative insufficiency may persist for up to 12 months after discontinuation of therapy; therefore, in any situation of stress occurring during that period, hormone therapy should be reinstituted.

The recommended approach to tapering prednisone is to withdraw the drug gradually rather than abruptly, in order to minimize the risk of adrenocortical insufficiency.

• The dosage should be decreased in small increments at appropriate time intervals until the lowest dosage that maintains an adequate clinical response is reached 2.
• Constant monitoring is needed to adjust the dosage as necessary, taking into account changes in the patient's clinical status and individual drug responsiveness 2.
• In situations where the patient is exposed to stressful situations, the dosage of prednisone may need to be increased temporarily to prevent adrenal insufficiency 2.

From the Research

Tapering Prednisone

• The process of tapering prednisone is crucial to avoid adrenal insufficiency, and the optimal tapering regimen may vary depending on the individual and the underlying condition 3, 4.
• A study on cardiac sarcoidosis found that prednisone-tapering regimens containing infliximab were superior to those containing prednisone alone or prednisone plus methotrexate in terms of reaching a daily prednisone dose of 7.5 mg or less for more than 6 months 3.
• Another study compared hydrocortisone and prednisone in glucocorticoid replacement therapy post-adrenalectomy for Cushing's syndrome and found that both groups had similar baseline responses to adrenalectomy, but hydrocortisone showed advantages over prednisone in improving liver function 4.
• However, there is limited data on the optimal tapering regimen for prednisone, and further studies are needed to determine the best approach 5, 6.

Considerations for Tapering Prednisone

• The dose and duration of prednisone treatment should be carefully considered when tapering the medication to avoid adrenal insufficiency 4, 7.
• A study on continuous subcutaneous hydrocortisone infusion found that this method permitted individualized glucocorticoid delivery and mimicked a more physiologic cortisol pattern compared with oral glucocorticoid therapy 7.
• The use of infliximab in combination with prednisone may be beneficial in certain conditions, such as cardiac sarcoidosis, but further studies are needed to confirm this 3.
• The choice of glucocorticoid replacement therapy, such as hydrocortisone or prednisone, should be based on individual patient needs and responses to treatment 4.