What is a good taper course of prednisone (corticosteroid)?

Prednisone Tapering Recommendations

The optimal prednisone taper involves gradually reducing the dose based on the initial dose, treatment duration, and underlying condition, with a general approach of tapering to 10 mg/day within 4-8 weeks, then reducing by 1 mg every 4 weeks until discontinuation. 1

General Principles of Prednisone Tapering

• Prednisone tapering should be individualized based on disease activity, laboratory markers, and adverse events 1
• Morning administration (before 9 am) is recommended to minimize adrenal suppression 2
• Single daily dosing is preferred over divided doses except in special situations such as prominent night pain while on low doses (<5 mg daily) 1
• For courses longer than 3 weeks, tapering is necessary to prevent adrenal insufficiency 1

Specific Tapering Schedules by Initial Dose

For High Initial Doses (>30 mg/day)

• Initial tapering: Reduce dose to 10 mg/day within 4-8 weeks 1
• For inflammatory arthritis: Prednisone 20 mg daily for 2-4 weeks, then taper over 4-8 weeks until grade 1 or resolution 1
• For sarcoidosis: Taper steroids over 2-4 months, depending on response 1

For Medium Initial Doses (10-30 mg/day)

• Taper by 5 mg every week until reaching 10 mg/day 1
• Then slow the taper to 2.5 mg/week until reaching 5 mg/day 1

For Low Doses (<10 mg/day)

• Taper by 1 mg every 4 weeks 1
• Alternative approach: Use 1.25 mg decrements with alternate-day schedules (e.g., 10/7.5 mg alternate days) 1

Disease-Specific Recommendations

For Polymyalgia Rheumatica

• Initial dose: 12.5-25 mg prednisone equivalent daily 1
• Initial tapering: Reduce to 10 mg/day within 4-8 weeks 1
• Maintenance tapering: Reduce by 1 mg every 4 weeks until discontinuation 1
• For relapse: Increase to pre-relapse dose and gradually decrease within 4-8 weeks to the dose at which relapse occurred 1

For Inflammatory Myopathies

• Initial dose: 0.5-1 mg/kg/day (typically 60-80 mg/day) 1
• Taper by 10 mg every 2 weeks until reaching 30 mg/day 1
• Then taper by 5 mg every 2 weeks until reaching 20 mg/day 1
• Then taper by 2.5 mg every 2 weeks until completed 1
• At 10 mg/day, may slow to 1 mg every 2-4 weeks until completed 1

For Autoimmune Hepatitis

• For adults: Start with prednisone 30 mg/day with azathioprine, taper to 10 mg/day for maintenance 1
• For children: Start with 1-2 mg/kg/day (up to 60 mg/day), taper over 6-8 weeks to 0.1-0.2 mg/kg daily or 5 mg daily 1

Special Considerations

For Short-Term Therapy (<3 weeks)

• May not require tapering if treatment duration is short 3, 4
• However, caution is advised as some experts recommend considering patients who received 1-4 weeks of suppressive treatment as potentially having compromised HPA axis for up to one year 4

For Long-Term Therapy

• Consider alternate-day therapy to minimize side effects 2
• For patients on chronic therapy, consider calcium (800-1000 mg/day) and vitamin D (400-800 units/day) supplementation 5
• Slow tapering using 1 mg decrements every couple weeks to a month is recommended 5

For Relapse During Tapering

• Return to the pre-relapse dose 1
• Gradually decrease within 4-8 weeks to the dose at which relapse occurred 1
• Consider adding steroid-sparing agents if multiple relapses occur 1

Common Pitfalls to Avoid

• Using high-dose prednisone (1.0 mg/kg/day) when lower doses (0.2-0.5 mg/kg/day) may be effective with fewer side effects 6
• Tapering too quickly, which may lead to disease flare or adrenal insufficiency 1
• Failing to monitor for steroid-related side effects during tapering 1
• Not providing patients with clear instructions about tapering schedule and signs of adrenal insufficiency 1
• Stopping prednisone abruptly after prolonged use, which can lead to adrenal crisis 2

Remember that the optimal tapering schedule should balance disease control against the risks of prolonged steroid exposure, with the goal of using the minimum effective dose for the shortest possible time.