Is every other day dosing (EOD) safe on the last week of a steroid taper with prednisone?

Every Other Day Dosing in the Last Week of a Prednisone Taper

Yes, every other day dosing is safe and effective during the last week of a prednisone taper, and is actually recommended by the FDA drug label for prednisone.

Rationale for Every Other Day Dosing

The FDA drug label for prednisone specifically supports alternate day therapy as a therapeutic technique primarily designed for patients on long-term corticosteroid therapy 1. This approach offers several advantages:

1. Reduced HPA axis suppression: Every other day dosing allows for re-establishment of more normal hypothalamic-pituitary-adrenal (HPA) activity on the off-steroid day 1
2. Maintained therapeutic effect: The anti-inflammatory effects of corticosteroids persist longer than their physical presence and metabolic effects 1
3. Reduced adverse effects: Escape from constantly elevated plasma levels, even for short periods, may help protect against undesirable pharmacologic effects 1

Evidence Supporting Every Other Day Dosing

Multiple guidelines and studies support alternate day dosing of prednisone:

• The KDIGO Clinical Practice Guideline for Glomerulonephritis explicitly recommends alternate-day medication for maintenance therapy in various conditions 2
• Research has shown that a single morning dose of prednisone produces considerably less adrenal suppression compared to divided doses throughout the day 1
• Studies comparing tapering versus non-tapering regimens have found no difference in relapse rates or adrenal suppression between the approaches 3, 4

Implementation of Every Other Day Dosing

When implementing every other day dosing during the final week of a taper:

1. Transition timing: Change to alternate day therapy once disease control has been established 1
2. Dosing approach: For the final week, administer the lowest effective dose every other day 2
3. Monitoring: Watch for symptom flare-ups which may occur in the latter part of the off-steroid day 1

Special Considerations

• Difficulty transitioning: If transitioning to alternate day therapy is difficult, it may be helpful to triple or even quadruple the daily maintenance dose and administer this every other day rather than just doubling the daily dose 1
• Individualization: It's important to tailor the therapy to each patient, as complete control of symptoms may not be possible in all patients 1
• Adrenal insufficiency: Never stop prednisone abruptly due to risk of adrenal insufficiency 1

Conditions Where Every Other Day Dosing Is Specifically Recommended

The KDIGO guidelines specifically recommend alternate-day prednisone for:

• Maintenance therapy in nephrotic syndrome 2
• Following remission induction in patients with infrequent relapses 2
• Maintenance therapy in frequently relapsing or steroid-dependent conditions 2

Conclusion

Every other day dosing in the last week of a prednisone taper is not only safe but may be preferable to daily dosing due to reduced HPA axis suppression while maintaining therapeutic effect. This approach is supported by both the FDA drug label and clinical practice guidelines.