What is the recommended protocol for a prednisone (corticosteroid) taper?

Prednisone Tapering Protocol

The recommended protocol for prednisone tapering is to reduce the dose by 5mg every week until reaching 10mg daily, then by 2.5mg every 3 days until discontinuation, with the goal of minimizing the risk of adrenal insufficiency while effectively managing the underlying condition. 1

General Principles of Prednisone Tapering

• Administer prednisone in the morning (before 9 am) to align with the body's natural cortisol rhythm 2
• Take with food or milk to reduce gastric irritation 2
• Never discontinue prednisone abruptly due to risk of adrenal insufficiency 2
• Tapering speed depends on:
  • Duration of therapy
  • Total daily dose
  • Underlying condition being treated
  • Individual patient response

Standard Tapering Schedule

For patients on moderate to high doses of prednisone:

1. Initial phase: Reduce by 5mg weekly until reaching 10mg daily 1
2. Final phase: Reduce by 2.5mg every 3 days until discontinuation 1

Alternative Tapering Schedule (Mayo Clinic)

For longer-term or higher-dose therapy:

• Reduce by 10mg every 2 weeks until 30mg/day
• Then by 5mg every 2 weeks until 20mg/day
• Then by 2.5mg every 2 weeks until 10mg/day
• Finally by 1mg every 2-4 weeks until completed 1

Condition-Specific Tapering Recommendations

For Immune Checkpoint Inhibitor Toxicities

• For dermatologic reactions: Prednisone 0.5-1 mg/kg/day tapered over 2 weeks 3
• For colitis: Taper over 4-6 weeks for grade 2 symptoms 3

For Rheumatoid Arthritis

• Taper slowly using 1mg decrements every 2-4 weeks 4
• Daily divided doses (e.g., 5mg twice daily) may be more effective than single daily dosing 4

Managing Tapering Risks

• Monitor for signs of adrenal insufficiency during tapering:

  • Fatigue
  • Weakness
  • Dizziness
  • Nausea
  • Low blood pressure
  • Hypoglycemia

• If symptoms worsen during tapering:

  • Increase dose to pre-relapse level
  • Maintain for 2-4 weeks until symptoms improve
  • Resume tapering more gradually 1

• Consider split dosing for patients experiencing night pain while tapering below 5mg daily 1

Preventive Care During Prednisone Therapy

• For courses exceeding 3 months:

  • Calcium supplementation (800-1000mg daily)
  • Vitamin D supplementation (400-800 IU daily) 1, 4

• For high-dose therapy (>20mg daily for >2 weeks):

  • Influenza vaccination
  • Pneumococcal vaccination 1

Common Pitfalls to Avoid

1. Abrupt discontinuation: Can cause adrenal crisis, which may be life-threatening 2
2. Tapering too quickly: May lead to symptom flare or adrenal insufficiency
3. Inadequate monitoring: Patients should be followed every 4-8 weeks during the first year 1
4. Neglecting preventive care: Failure to provide calcium and vitamin D supplementation increases osteoporosis risk
5. Ignoring drug interactions: Certain medications can affect prednisone metabolism 2

Remember that hypothalamic-pituitary-adrenal axis suppression may occur in any patient receiving more than 7.5mg of prednisolone equivalent daily for more than 3 weeks, highlighting the importance of careful tapering 1.