What is the suggested prednisone (corticosteroid) taper course for a rheumatoid arthritis (RA) flare?

From the Guidelines

For a rheumatoid arthritis flare, a typical prednisone taper would start with 15-20 mg daily for 3-5 days, then decrease by 5 mg every 3-5 days until reaching 5 mg, followed by a slower reduction of 1 mg every 3-5 days until discontinuation, as suggested by general clinical guidelines 1. The entire taper usually lasts 2-3 weeks.

• For more severe flares, a higher initial dose of 30-40 mg may be needed.
• Take the medication in the morning with food to minimize gastrointestinal side effects and sleep disturbances.
• While tapering, monitor for symptom recurrence, which may indicate the need to slow the taper.
• Continue your regular rheumatoid arthritis medications during the taper.
• Prednisone works by reducing inflammation through suppression of inflammatory mediators and immune cell activity.
• Sudden discontinuation should be avoided as it can lead to adrenal insufficiency.
• If you experience concerning side effects like severe mood changes, visual disturbances, or signs of infection, contact your healthcare provider immediately. However, it's essential to note that the provided evidence primarily focuses on polymyalgia rheumatica (PMR) management rather than rheumatoid arthritis (RA) specifically 1. In the context of RA management, the European League Against Rheumatism (EULAR) recommendations suggest using low-dose glucocorticoids for up to 6 months and tapering them as rapidly as clinically feasible 1. Given the lack of specific guidance on prednisone tapering for RA flares in the provided evidence, the suggested taper course is based on general clinical principles and may need to be adjusted according to individual patient needs and response to treatment.

From the Research

Suggested Prednisone Taper Course for Rheumatoid Arthritis Flare

• The optimal prednisone taper course for a rheumatoid arthritis flare is not well-established, but some studies provide guidance on tapering strategies 2, 3.
• A study published in 2020 found that continuing prednisone 5 mg per day for 24 weeks provided better disease control than tapering prednisone to 0 mg per day at week 16 in patients with rheumatoid arthritis who had achieved low disease activity with tocilizumab and at least 24 weeks of glucocorticoid treatment 2.
• Another study published in 2021 found that short-term use of low-dose prednisone monotherapy (mean dose 8 mg/day, mean treatment duration 42.2 days) was effective in inducing remission in newly diagnosed rheumatoid arthritis patients 4.
• A systematic review published in 2020 found that there is no high-level evidence to guide tapering of corticosteroids after extended courses of medium- to high-dose treatment regimens, and that current guidelines rely heavily on expert opinion and small case series with a trial-and-error approach 3.

Tapering Regimens

• The SEMIRA trial used a tapering regimen of prednisone 5 mg per day for 4 weeks, followed by a taper to 0 mg per day at week 16 2.
• The study published in 2021 used a short-term tapering regimen of prednisone (< 10 mg/day) for up to 6 months 4.
• The systematic review published in 2020 found that different tapering regimens were used in the included studies, but that there was no consistent evidence to support one regimen over another 3.

Disease Activity and Flares

• A study published in 2014 found that patients with rheumatoid arthritis experienced flares more often when they were in higher disease activity states than when they were in remission 5.
• The SEMIRA trial found that disease activity control was superior in patients who continued prednisone 5 mg per day for 24 weeks compared to those who tapered prednisone to 0 mg per day at week 16 2.
• The study published in 2021 found that short-term use of low-dose prednisone monotherapy was effective in inducing remission in newly diagnosed rheumatoid arthritis patients, with 54.2% of patients reaching remission 4.