What is the ideal way to taper prednisone (corticosteroid)?

Ideal Prednisone Tapering Protocol

The ideal way to taper prednisone is to reduce by 10 mg every 2 weeks until reaching 20 mg/day, then 5 mg every 2 weeks until reaching 10 mg/day, followed by 2.5 mg every 2 weeks until 5 mg/day, and finally by 1 mg every 2-4 weeks until discontinuation. 1

General Tapering Principles

Initial Tapering Phase (Higher Doses)

• For patients on high-dose prednisone (>20 mg/day):
  • Reduce by 10 mg every 2 weeks until reaching 20 mg/day 1
  • Example: 60 mg → 50 mg → 40 mg → 30 mg → 20 mg (each step lasting 2 weeks)

Middle Tapering Phase (Moderate Doses)

• When reaching 20 mg/day:
  • Slow the taper to 5 mg decrements every 2 weeks until reaching 10 mg/day 1
  • Example: 20 mg → 15 mg → 10 mg (each step lasting 2 weeks)

Final Tapering Phase (Low Doses)

• When reaching 10 mg/day:
  • Further slow the taper to 2.5 mg decrements every 2 weeks until reaching 5 mg/day 1
  • Below 5 mg/day, taper by 1 mg every 2-4 weeks until discontinuation 1
  • Example: 10 mg → 7.5 mg → 5 mg → 4 mg → 3 mg → 2 mg → 1 mg → off

Administration Timing

• Administer prednisone as a single morning dose (before 9 am) rather than divided doses 1, 2
• Morning administration aligns with the body's natural cortisol rhythm and minimizes adrenal suppression 2
• Exception: For patients experiencing prominent night pain while on doses below 5 mg daily, divided dosing may be considered 3

Special Considerations

Duration of Initial Dose

• Maintain the initial therapeutic dose for 2-4 weeks until a satisfactory response is noted before beginning the taper 2
• If no satisfactory clinical response is observed after a reasonable period, consider discontinuing prednisone and transferring to alternative therapy 2

Alternative Tapering Approaches

• Alternate-day dosing (e.g., 10 mg/7.5 mg on alternate days) may be considered to reduce steroid-related side effects 3, 1
• This approach can be particularly useful during the final tapering phase

Managing Relapse During Tapering

• If relapse occurs during tapering, increase the dose to the pre-relapse level and maintain for 2-4 weeks until symptoms improve 1
• After stabilization, resume tapering more gradually than before 1
• Consider adding a steroid-sparing agent if multiple relapses occur 1

Monitoring and Side Effect Management

• Monitor for steroid-related side effects including cosmetic changes, osteopenia, hypertension, hyperglycemia, and mood changes 1
• Consider calcium and vitamin D supplementation for courses exceeding 3 months 1
• Patients on prednisone >20 mg daily for >2 weeks should receive influenza and pneumococcal vaccinations 1
• Take prednisone with food or milk to reduce gastric irritation 2

Important Cautions

• Never stop prednisone abruptly after prolonged use due to risk of adrenal insufficiency 2
• Hypothalamic-pituitary-adrenal axis suppression may occur in any patient receiving more than 7.5 mg of prednisolone equivalent daily for more than 3 weeks 3
• High-dose prednisone (>30 mg/day) is strongly discouraged for long-term use due to increased risk of adverse effects 3, 1

Evidence Quality Considerations

While there is consensus on general tapering principles, it's worth noting that many recommendations are based on clinical experience rather than randomized controlled trials. Some studies have questioned whether tapering is always necessary for short courses of steroids 4, 5, but for longer-term use (>3 weeks), tapering is essential to prevent adrenal insufficiency 3.