Prednisone 40mg Tapering Schedule
The recommended tapering schedule for prednisone 40mg is to reduce the dose gradually by 1mg every 4 weeks (or by 1.25mg decrements using alternate day schedules) until discontinuation, after achieving an initial reduction to 10mg/day within 4-8 weeks. 1
Initial Tapering Phase (First 4-8 weeks)
- Start with 40mg prednisone daily as a single morning dose
- Gradually reduce to 10mg/day within 4-8 weeks following this schedule:
- Weeks 1-2: 40mg daily
- Weeks 3-4: 30mg daily
- Weeks 5-6: 20mg daily
- Weeks 7-8: 10mg daily
Maintenance Tapering Phase (After reaching 10mg)
- Once at 10mg daily, slow the taper to 1mg reduction every 4 weeks 1, 2
- Alternative approach for doses below 10mg: Use alternate-day dosing
- Example: 10mg/7.5mg on alternate days, then 7.5mg/5mg on alternate days, etc.
Important Considerations
Monitoring Schedule
- Follow-up every 4-8 weeks during the first year of treatment 1
- Monitor for:
- Signs of disease relapse
- Steroid-related side effects
- Adrenal insufficiency symptoms (fatigue, weakness, dizziness)
Special Situations
- For night pain while tapering below 5mg daily, consider split dosing rather than once-daily dosing 1
- If relapse occurs during tapering:
- Increase dose to the pre-relapse dose
- Decrease gradually (within 4-8 weeks) to the dose at which relapse occurred
- Resume slower tapering once stabilized 1
Precautions
- Patients on prednisone >20mg daily for >2 weeks should receive:
- Influenza vaccination
- Pneumococcal vaccination
- Vitamin D and calcium supplementation if treatment duration exceeds 3 months 1
- Avoid live attenuated vaccines during treatment 1
Evidence Quality Assessment
The European League Against Rheumatism/American College of Rheumatology guidelines provide the most comprehensive recommendations for prednisone tapering 1. While these guidelines were developed for polymyalgia rheumatica, the tapering principles apply broadly to systemic corticosteroid therapy. Research studies examining tapering versus non-tapering regimens for short-term use (8 days) found no difference in relapse rates or adrenal suppression 3, 4, but these findings cannot be extrapolated to longer-term therapy like a 40mg starting dose.
The recommendation to taper by 1mg every 4 weeks after reaching 10mg daily is particularly important, as more rapid tapering at lower doses increases the risk of disease relapse and adrenal insufficiency 1, 5.
For most conditions requiring prednisone 40mg, this gradual tapering approach balances the need to minimize steroid exposure while preventing disease relapse and adrenal crisis, ultimately optimizing morbidity, mortality, and quality of life outcomes.