What is the general rule for tapering the dose of prednisolone (corticosteroid) in patients on long-term therapy?

General Rule for Prednisolone Tapering Dose

For patients on long-term prednisolone therapy, the recommended tapering approach is to reduce the daily oral prednisolone dose by 1 mg every 4 weeks once remission is achieved, until discontinuation, while maintaining clinical remission. 1

Principles of Prednisolone Tapering

Initial Tapering Phase

• For patients on high-dose therapy, first taper to 10 mg/day prednisolone equivalent within 4-8 weeks 1
• For patients with acute conditions (like asthma exacerbations), short courses (3-10 days) can be stopped without tapering 1

Maintenance Phase Tapering

• Once remission is achieved, taper daily oral prednisolone by 1 mg every 4 weeks 1
• Alternative approach for those without 1 mg tablets: use alternate day dosing (e.g., 10/7.5 mg on alternate days) 1
• Continue gradual reduction until complete discontinuation, provided remission is maintained 1

Disease-Specific Considerations

Polymyalgia Rheumatica (PMR)

• Initial dose: 12.5-25 mg prednisolone daily
• Initial taper: Reduce to 10 mg/day within 4-8 weeks
• Maintenance taper: 1 mg every 4 weeks until discontinuation 1

Autoimmune Hepatitis

• From 20 mg daily: reduce by 5 mg every week until 10 mg/day
• Below 10 mg: reduce by 2.5 mg/week until 5 mg daily
• Continue maintenance regimen until disease resolution 1

Bullous Pemphigoid

• Begin tapering 15 days after disease control
• Aim to stop treatment 4-12 months after initiation 1

Special Considerations

Relapse Management

• If relapse occurs: Increase prednisolone to pre-relapse dose
• Then gradually decrease (within 4-8 weeks) to the dose at which relapse occurred
• Resume tapering schedule once stabilized 1

Monitoring During Tapering

• Regular assessment of disease activity markers
• Laboratory monitoring appropriate to the condition
• Assessment for steroid-related side effects
• Follow-up visits every 4-8 weeks in first year, every 8-12 weeks in second year 1

Common Pitfalls and Caveats

• Avoid abrupt discontinuation after long-term therapy, as this may lead to adrenal insufficiency 2
• For short-course therapy (≤10 days), tapering is generally unnecessary and does not prevent relapse 1, 3
• Patients on long-term corticosteroid treatment should be monitored for bone disease with baseline and annual bone mineral densitometry 1
• Consider steroid-sparing agents for patients requiring long-term therapy or experiencing significant side effects 1
• The most recent evidence suggests that more rapid tapering may be feasible in some conditions (like myasthenia gravis) when combined with steroid-sparing agents 4

Remember that while these are general guidelines, the FDA label emphasizes that "dosage requirements are variable and must be individualized on the basis of the disease under treatment and the response of the patient." 2