How to taper off long-term use of prednisone (corticosteroid)?

From the Guidelines

Weaning off long-term prednisone should always be done gradually under medical supervision to avoid withdrawal symptoms and adrenal crisis, with a tapering schedule personalized based on the patient's specific condition, duration of prednisone use, and how their body responds. The typical approach involves reducing the dose by 2.5-5 mg every 3-7 days if the patient has been taking more than 20 mg daily, as suggested by 1. For lower doses (5-20 mg), reductions of 1-2.5 mg every 1-2 weeks are common, while doses below 5 mg may require even slower tapering of 0.5-1 mg every 2-4 weeks.

Key Considerations

• The patient's pre-existing conditions, such as diabetes mellitus or an immune-compromised status, and their age, should be carefully evaluated when tapering prednisone, as certain patients may require special attention 1.
• A multidisciplinary approach may be necessary in the management of certain steroid-related complications, and institutional guidelines should be considered in decision-making 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, as recommended by 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 for certain conditions 1.

Tapering Schedule

• Reductions should be made gradually, with close monitoring for symptoms of adrenal insufficiency, such as fatigue, weakness, dizziness, nausea, or joint pain, which could indicate the taper is happening too quickly 1.
• Alternate-day dosing may be prescribed during the later stages of tapering to help the adrenal glands recover.
• Some patients may benefit from temporary supportive medications to manage symptoms of the underlying condition during the tapering process.

Important Reminders

• Long-term prednisone use suppresses the body's natural cortisol production, and a gradual taper allows the adrenal glands time to resume normal function.
• Patients should be warned about possible steroid withdrawal syndrome, including non-specific symptoms such as weakness, nausea, and arthralgia, as noted by 1.

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If after long-term therapy the drug is to be stopped, it is recommended that it be withdrawn gradually rather than abruptly Although many of the undesirable features of corticosteroid therapy can be minimized by alternate day therapy, as in any therapeutic situation, the physician must carefully weigh the benefit-risk ratio for each patient in whom corticoid therapy is being considered. The initial dosage of PredniSONE tablets may vary from 5 mg to 60 mg per day, depending on the specific disease entity being treated. After a favorable response is noted, the proper maintenance dosage should be determined by decreasing the initial drug dosage in small increments at appropriate time intervals until the lowest dosage which will maintain an adequate clinical response is reached.

To taper off long-term use of prednisone, it is recommended to:

• Withdraw the drug gradually rather than abruptly 2
• Decrease the dosage in small increments at appropriate time intervals until the lowest dosage that maintains an adequate clinical response is reached 2
• Consider alternate day therapy to minimize undesirable effects, but carefully weigh the benefit-risk ratio for each patient 2
• Monitor the patient's condition closely during the tapering process and adjust the dosage as needed 2

From the Research

Tapering Off Long-Term Use of Prednisone

To taper off long-term use of prednisone, the following steps can be considered:

• Gradually reduce the dose of prednisone over a period of time, such as 3 months, to allow the body to adjust and reduce the risk of adrenal insufficiency 3
• Monitor disease activity and adjust the tapering schedule as needed to minimize the risk of flares 3
• Consider the cumulative dose and exposure to prednisone, as these factors can increase the risk of adrenal insufficiency 4
• Assess adrenal function before and after tapering, using tests such as the short Synacthen test, to identify patients with impaired adrenal function 4, 5
• Be aware of the potential symptoms of adrenal insufficiency, such as fatigue, arthralgias, and muscular weakness, and monitor patients closely during the tapering process 5
• Consider alternative tapering regimens, such as a rapid taper to 5 mg/day followed by a prolonged period at this dose, to minimize the total dose of prednisone and reduce the risk of relapse 6
• Educate patients on the risks of glucocorticoid-induced adrenal insufficiency and the importance of gradual tapering to minimize this risk 7

Factors Affecting the Risk of Adrenal Insufficiency

The risk of adrenal insufficiency during prednisone tapering is affected by several factors, including:

• Duration of glucocorticoid therapy: longer duration increases the risk of adrenal insufficiency 4, 5
• Mode of administration: oral administration may be associated with a higher risk of adrenal insufficiency compared to other modes of administration 7
• Glucocorticoid dose and potency: higher doses and more potent glucocorticoids increase the risk of adrenal insufficiency 4, 7
• Concomitant drugs that interfere with glucocorticoid metabolism: certain drugs may increase the risk of adrenal insufficiency by interfering with glucocorticoid metabolism 7
• Individual susceptibility: some patients may be more susceptible to adrenal insufficiency due to individual factors, such as age or underlying medical conditions 7

Monitoring and Assessment

Regular monitoring and assessment are crucial during the tapering process to minimize the risk of adrenal insufficiency and ensure a successful taper. This includes:

• Monitoring disease activity and adjusting the tapering schedule as needed 3
• Assessing adrenal function using tests such as the short Synacthen test 4, 5
• Monitoring patients closely for symptoms of adrenal insufficiency, such as fatigue, arthralgias, and muscular weakness 5
• Educating patients on the risks of glucocorticoid-induced adrenal insufficiency and the importance of gradual tapering 7