How should I further taper down my prednisone (corticosteroid) dose after 45 days of treatment for nivolumab (opdivo) induced pneumonitis, currently taking 25mg in the morning and 10mg in the evening?

Prednisone Tapering for Nivolumab-Induced Pneumonitis

For nivolumab-induced pneumonitis, you should taper your prednisone by 5 mg every 1-2 weeks until you reach 10 mg daily, then slow to 2.5 mg decrements every 2 weeks, and finally 1 mg decrements every 2-4 weeks until complete discontinuation.

Tapering Schedule Based on Current Dose

You're currently taking 35 mg total daily (25 mg AM + 10 mg PM). Here's how to proceed:

1. First phase (from 35 mg to 10 mg):

   • Week 1-2: Reduce to 30 mg daily (20 mg AM + 10 mg PM)
   • Week 3-4: Reduce to 25 mg daily (15 mg AM + 10 mg PM)
   • Week 5-6: Reduce to 20 mg daily (10 mg AM + 10 mg PM)
   • Week 7-8: Reduce to 15 mg daily (10 mg AM + 5 mg PM)
   • Week 9-10: Reduce to 10 mg daily (10 mg AM)

2. Second phase (from 10 mg to 0 mg):

   • Week 11-12: Reduce to 7.5 mg daily
   • Week 13-14: Reduce to 5 mg daily
   • Week 15-16: Reduce to 2.5 mg daily
   • Week 17-20: Reduce to 1 mg daily
   • Week 21-24: Reduce to 0 mg (complete discontinuation)

Rationale and Evidence

The FDA label for prednisone emphasizes that "if after long-term therapy the drug is to be stopped, it is recommended that it be withdrawn gradually rather than abruptly" 1. This is particularly important after 45 days of treatment, as your hypothalamic-pituitary-adrenal (HPA) axis is likely suppressed.

For immune-related pneumonitis from checkpoint inhibitors like nivolumab, a gradual taper is essential to prevent recurrence. Multiple case reports have documented pneumonitis recurrence during or after prednisone tapering, even months after nivolumab discontinuation 2, 3.

Monitoring During Taper

• Monitor for signs of pneumonitis recurrence: new or worsening cough, shortness of breath, chest pain, or fever
• If symptoms recur during tapering, return to the previous effective dose that controlled symptoms 4
• Consider chest imaging if symptoms suggest recurrence

Important Precautions

• Never stop prednisone abruptly due to risk of adrenal insufficiency 4, 1
• Take your prednisone in the morning (before 9 AM) to minimize adrenal suppression 1
• Consider calcium and vitamin D supplementation if not already taking them
• Monitor for signs of infection, as corticosteroids can mask symptoms
• Be aware that pneumonitis can recur even months after nivolumab discontinuation 2, 3

Special Considerations

• If you experience a relapse of pneumonitis symptoms during the taper, return to the previous effective dose and hold at that dose for 2-3 weeks before attempting to taper again 4
• Some patients with immune-related pneumonitis may require long-term low-dose prednisone maintenance (5-10 mg daily) to prevent recurrence 5
• The risk of recurrent pneumonitis appears higher with diffuse alveolar damage pattern on imaging compared to organizing pneumonia pattern 6

This tapering schedule balances the need to gradually withdraw corticosteroid therapy while minimizing the risk of pneumonitis recurrence and other adverse effects of prolonged steroid use.