What is the recommended steroid taper from Decadron (dexamethasone) 6 mg twice a day (BID)?

Dexamethasone Taper Protocol from 6 mg BID

The recommended steroid taper from dexamethasone 6 mg twice daily is to reduce the dose by 2 mg every 4-7 days until discontinuation, with a slower taper of 1 mg decrements when reaching lower doses (≤4 mg/day). 1

Initial Approach to Tapering

When tapering from dexamethasone 6 mg BID (12 mg/day total), follow this algorithm:

1. First reduction: Decrease from 6 mg BID to 5 mg BID for 4-7 days
2. Second reduction: Decrease to 4 mg BID for 4-7 days
3. Third reduction: Decrease to 3 mg BID for 4-7 days
4. Fourth reduction: Decrease to 2 mg BID for 4-7 days
5. Fifth reduction: Decrease to 1 mg BID for 4-7 days
6. Final step: Discontinue

Considerations for Taper Speed

The taper speed should be adjusted based on:

• Duration of prior steroid therapy: Longer courses require slower tapers
• Underlying condition being treated: Some conditions may require more gradual tapering
• Patient response: Monitor for signs of steroid withdrawal syndrome

For patients who have been on high-dose dexamethasone for more than 3 weeks, a more gradual taper is recommended to avoid adrenal insufficiency and withdrawal symptoms 1.

Monitoring During Taper

During the taper, monitor for:

• Signs of adrenal insufficiency: Fatigue, weakness, dizziness, nausea, hypotension
• Withdrawal symptoms: Myalgia, arthralgia, headache, fatigue, nausea
• Recurrence of the underlying condition: May require slowing the taper

Special Considerations

• Higher risk of withdrawal: Patients on dexamethasone may experience more pronounced withdrawal symptoms compared to those on prednisone 2
• Conversion to alternate-day dosing: When reaching lower doses (≤4 mg/day), consider converting to alternate-day dosing to reduce HPA axis suppression
• Stress dosing education: Patients should be educated about stress dosing for illness or procedures during and after the taper 1

Pitfalls to Avoid

1. Tapering too quickly: Can lead to adrenal crisis or withdrawal syndrome
2. Tapering too slowly: Increases risk of steroid-related adverse effects
3. Failure to monitor: Missing early signs of withdrawal or adrenal insufficiency
4. Abrupt discontinuation: Never abruptly stop dexamethasone after prolonged use

If withdrawal symptoms occur during tapering, return to the previous well-tolerated dose and slow the taper rate further, reducing by smaller increments (e.g., 0.5 mg) and extending the time between dose reductions to 1-2 weeks 1.