What is the proper protocol for tapering oral corticosteroids (e.g. prednisone) in a patient on a high dose?

From the Guidelines

Tapering oral corticosteroids like prednisone in patients on high doses should be done gradually, starting with a reduction of 5 mg every week until 10 mg/day is achieved, and then further reducing by 2.5 mg/week, as this approach is associated with a lower risk of adrenal insufficiency and other corticosteroid-related side effects 1. When tapering oral corticosteroids, it is essential to consider the patient's individual response and the underlying condition being treated.

• The tapering schedule should be adjusted based on the patient's symptoms and laboratory results.
• Patients on long-term corticosteroid treatment should 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.
• Morning dosing is preferred to mimic natural cortisol rhythms.
• The underlying condition being treated must remain stable during tapering; if symptoms flare, temporarily return to the previous effective dose before attempting a slower taper.
• Patients should be monitored for signs of adrenal insufficiency during tapering, including fatigue, weakness, nausea, hypotension, and hypoglycemia. It is crucial to prioritize the patient's safety and adjust the tapering schedule accordingly, as abrupt discontinuation of corticosteroids can lead to potentially life-threatening adrenal crisis.
• A more gradual approach to tapering, such as reducing the dose by 1 mg every 2-4 weeks, may be necessary in some patients to prevent adrenal insufficiency.
• The final taper from physiologic doses should be even more gradual, often reducing by 1 mg every 2-4 weeks.

From the FDA Drug Label

If after long-term therapy the drug is to be stopped, it recommended that it be withdrawn gradually rather than abruptly

• The proper protocol for tapering oral corticosteroids, such as prednisone, in a patient on a high dose is to withdraw the drug gradually rather than abruptly.
• The dosage requirements are variable and must be individualized based on the disease under treatment and the response of the patient.
• After a favorable response is noted, the maintenance dosage should be determined by decreasing the initial drug dosage in small decrements at appropriate time intervals until the lowest dosage which will maintain an adequate clinical response is reached 2.

From the Research

Tapering Oral Steroids

To properly taper oral corticosteroids, such as prednisone, in a patient on a high dose, several factors must be considered, including the duration of therapy, the dose, and the individual patient's response to tapering 3.

• Rapid Tapering: Moderate-to-high dose glucocorticoid therapy may be tapered rapidly to near-physiological doses while watching for features of disease reactivation 3.
• Slower Tapering: Once close to the physiological dose, tapering should be slower and at longer intervals to allow for recovery of the hypothalamic-pituitary-adrenal (HPA) axis 3.
• HPA Axis Recovery: The time required for HPA axis recovery is longer if the period of suppression has been long, and in such cases, tapering should be slower over a few months to even a year 3.

Disease-Specific Considerations

The approach to tapering oral steroids may vary depending on the underlying disease being treated. For example:

• Asthma: In acute asthma, a study suggested that steroid tapering may be unnecessary, and a personal asthma management plan with a reserve course of prednisolone may be more appropriate 4. However, expert consensus recommends attempting OCS tapering in all patients with asthma receiving maintenance OCS therapy, with personalization of tapering rhythm and speed 5.
• Nonmalignant Hematologic Diseases: In patients with nonmalignant hematologic diseases, high disease relapse rates during the tapering period or upon drug discontinuation result in long-term corticosteroid use, increasing the risk of infection 6.

Monitoring and Prevention of Complications

During tapering, it is essential to monitor for and prevent infectious complications associated with systemic corticosteroids 6, 7.

• Infection Risk: Corticosteroids are associated with a length-of-treatment and dose-dependent risk for infection, and screening and antimicrobial prophylaxis may be indicated in patients on high-dose corticosteroids 6.
• Repository Steroids: Repository steroids have been shown to be as effective as tapering oral doses in preventing relapse after emergency treatment for asthma 7.