From the Guidelines
Steroid tapering should be individualized and gradual, with the goal of minimizing adrenal insufficiency and withdrawal symptoms, as recommended by the most recent guideline update 1. When tapering steroids, it's essential to consider the patient's condition, treatment duration, and steroid dose. For patients on short-term therapy (less than 3 weeks), tapering may not be necessary. However, for longer use, a gradual taper is recommended.
- A common approach is to reduce the dose by 10-20% every 1-2 weeks for prednisone doses above 40mg daily,
- then slow to 5-10% reductions every 1-2 weeks when below 20mg daily,
- as suggested by clinical practice guidelines 1. For example, a patient on prednisone 60mg daily might follow this schedule:
- 60mg for 1-2 weeks,
- then 50mg for 1-2 weeks,
- then 40mg for 1-2 weeks,
- then 30mg for 1-2 weeks,
- then 20mg for 1-2 weeks,
- followed by smaller decrements (17.5mg, 15mg, 12.5mg, 10mg, 7.5mg, 5mg, 2.5mg) until discontinuation. Alternate-day dosing may help minimize side effects during tapering, as discussed in the context of nephrotic syndrome management 1. Patients should be monitored for signs of adrenal insufficiency (fatigue, weakness, dizziness, nausea, hypotension) or disease flare-up during the taper. The tapering schedule should be slowed if symptoms recur, prioritizing the patient's safety and well-being, as emphasized in the management of immune-related adverse events 1. Gradual tapering allows the hypothalamic-pituitary-adrenal axis to recover normal function, which can take months after prolonged steroid use.
From the FDA Drug Label
The initial dosage of PredniSONE tablets may vary from 5 mg to 60 mg per day, depending on the specific disease entity being treated. ... After a favorable response is noted, the proper maintenance dosage should be determined by decreasing the initial drug dosage in small increments at appropriate time intervals until the lowest dosage which will maintain an adequate clinical response is reached. ... If after long-term therapy the drug is to be stopped, it is recommended that it be withdrawn gradually rather than abruptly
To taper steroids, the dosage should be decreased in small increments at appropriate time intervals until the lowest dosage that maintains an adequate clinical response is reached.
- Gradual tapering is recommended to minimize the risk of withdrawal symptoms and adrenal insufficiency.
- The tapering schedule should be individualized based on the patient's response and disease entity being treated.
- It is recommended to withdraw the drug gradually rather than abruptly after long-term therapy 2, 2, 2.
From the Research
Steroid Tapering Protocols
The recommended protocol for tapering steroids (corticosteroids) varies depending on the medical condition being treated.
- For patients with asthma, expert consensus statements suggest that oral corticosteroid (OCS) tapering should be attempted in all patients receiving maintenance OCS therapy, with personalization of tapering rhythm and speed 3.
- A study on acute asthma found that steroid tapering may be unnecessary, and a personal asthma management plan with a reserve course of prednisolone may be more appropriate 4.
- Another study on acute asthma found no difference in relapse rate between patients receiving an 8-day tapering dose of prednisone and those receiving 40 mg/day prednisone upon discharge from the emergency department 5.
Tapering Regimens
Different tapering regimens have been used in various studies, including:
- A standard tapering regimen of oral prednisolone starting with a daily dose of 50 mg and tapering over 8 weeks (50/40/30/25/20/15/10/5 mg) 6.
- An individualized tapering regimen based on the ulcer healing process, which was found to be effective in avoiding strictures after non-circumferential resection of Barrett's neoplasia 6.
- A tapering regimen used in patients with neuromyelitis optica spectrum disorder, where patients tapered their steroid dose from a median of 10 mg/day to 2.75 mg/day over a period of time 7.
Key Considerations
When tapering steroids, it is essential to consider the individual patient's response to treatment and adjust the tapering regimen accordingly.