How to order a prednisone (corticosteroid) taper?

From the Guidelines

To order a prednisone taper, reduce the dose by 5 mg every week until 10 mg/day are achieved, and then further reduce by 2.5 mg/week until 5 mg daily, as this approach has been shown to maintain remission while minimizing corticosteroid-related side effects 1. When tapering prednisone, it is essential to consider the individual patient's condition, prior steroid exposure, and treatment duration.

• The tapering regimen should be tailored to the patient's specific needs, taking into account factors such as cytopenia, postmenopausal state, thiopurine methyltransferase deficiency, osteoporosis, brittle diabetes, obesity, pregnancy, acne, malignancy, emotional lability, and hypertension 1.
• 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.
• Prednisolone can be used in place of prednisone in equivalent doses, and in Europe, prednisolone is preferred over prednisone, especially in individuals with severe cytopenia 1. The specific regimen should be adjusted based on the patient's response to treatment and the occurrence of any side effects.
• It is crucial to monitor patients for signs of adrenal insufficiency during tapering, including fatigue, weakness, dizziness, nausea, or hypotension.
• Always take prednisone with food to minimize gastrointestinal side effects, and administer the dose in the morning to mimic natural cortisol rhythm and reduce insomnia.

From the FDA Drug Label

If after long-term therapy the drug is to be stopped, it is recommended that it be withdrawn gradually rather than abruptly

• The FDA drug label recommends a gradual withdrawal of prednisone after long-term therapy, rather than an abrupt stop.
• Gradual tapering is necessary to minimize potential withdrawal symptoms and allow the body to adjust to the decrease in corticosteroid levels.
• The label does not provide a specific tapering schedule, emphasizing that dosage requirements are variable and must be individualized based on the disease under treatment and the patient's response 2.

From the Research

Ordering a Prednisone Taper

To order a prednisone taper, the following steps can be considered:

• Start with a high dose of prednisone (e.g., 15 mg/day) for a short period (e.g., 1-3 days) to quickly reduce inflammation 3
• Gradually taper the dose over time (e.g., 10 mg/day for 7 days, 5 mg/day for 1 year) to allow the body to adjust and minimize side effects 3
• Once the dose is near physiological levels (e.g., 5 mg/day), tapering can be slowed down and done at longer intervals (e.g., 1 mg/day/month) to allow for recovery of the hypothalamic-pituitary-adrenal (HPA) axis 4

Factors to Consider

When ordering a prednisone taper, the following factors should be considered:

• The patient's underlying condition and disease severity 5
• The risk of disease flare-up or symptoms of adrenal insufficiency 4
• The patient's history of steroid use and potential for HPA axis suppression 4
• The presence of any comorbidities or concomitant medications that may interact with prednisone 6

Tapering Regimens

Different tapering regimens have been studied, including:

• Rapid tapering (e.g., 1-2 weeks) versus slow tapering (e.g., several months) 6, 7
• Short-term treatment (e.g., 8-12 weeks) versus long-term treatment (e.g., several months) 7
• The use of short- or intermediate-acting glucocorticoid preparations (e.g., hydrocortisone or prednisolone) in physiological doses, administered in the morning to mimic the endogenous cortisol rhythm 4