Tapering Prednisolone from 40mg to 5mg in a PMR Patient After Bronchiectasis Exacerbation
For a PMR patient who has been on 5mg prednisolone daily and required 40mg for 11 days due to bronchiectasis exacerbation, taper the dose gradually to 10mg/day within 4-8 weeks, then reduce by 1mg every 4 weeks until reaching the previous maintenance dose of 5mg.
Initial Tapering Phase (First 4-8 Weeks)
The 2015 EULAR/ACR guidelines for PMR management provide clear recommendations for tapering prednisolone after treating an exacerbation:
- Begin by gradually reducing the dose from 40mg to 10mg/day within 4-8 weeks 1
- A reasonable approach would be:
- 40mg for 1 week
- 30mg for 1 week
- 20mg for 1-2 weeks
- 15mg for 1-2 weeks
- 10mg for 1-2 weeks
Secondary Tapering Phase (After Reaching 10mg)
Once the patient reaches 10mg/day:
- Continue tapering more slowly at a rate of 1mg every 4 weeks 1
- Alternative acceptable approach: 2.5mg reduction every 10 weeks 1
- Continue this gradual reduction until reaching the previous maintenance dose of 5mg
Monitoring During Tapering
- Follow up every 4-8 weeks during the first year of treatment 1
- Monitor for:
- Return of PMR symptoms (pain and stiffness in shoulder and pelvic girdle)
- Signs of bronchiectasis exacerbation
- Glucocorticoid-related adverse effects
Managing Relapse During Tapering
If PMR symptoms recur during tapering:
- Increase dose to the previously effective (pre-relapse) dose 1
- Then resume tapering more gradually after symptoms are controlled
Special Considerations
- For night pain while tapering below 5mg, consider split dosing rather than increasing the total daily dose 1
- If persistent breakthrough symptoms occur, reconsider the diagnosis 1
- Consider methotrexate (7.5-10mg/week) as a steroid-sparing agent if:
- Patient has frequent relapses during tapering
- Patient has risk factors for glucocorticoid-related adverse events
- Patient is unable to reduce prednisolone to target maintenance dose 1
Important Caveats
- Avoid abrupt discontinuation of prednisolone, which can lead to adrenal insufficiency 2
- The tapering schedule should be individualized based on symptom control and risk of adverse effects
- Patients with PMR typically require long-term low-dose glucocorticoid therapy (often 1-2 years or longer)
- The goal is to maintain disease control at the lowest effective dose (5mg in this case) to minimize adverse effects
This tapering approach aligns with current guidelines and balances the need to control both PMR and prevent bronchiectasis exacerbations while minimizing glucocorticoid-related adverse effects.