Guidelines for Prednisone Tapering from 40 mg
When tapering prednisone from 40 mg, the dose should be gradually reduced by approximately 5 mg every 1-2 weeks until reaching 10 mg/day, then more slowly at 1 mg decrements every 2-4 weeks thereafter to minimize risk of adrenal insufficiency and disease relapse. 1, 2
General Principles for Prednisone Tapering
- Tapering schedules should be individualized based on disease activity, laboratory markers, and monitoring for adverse events 2
- Initial tapering should aim to reduce the dose to 10 mg/day within 4-8 weeks 2
- Once at lower doses (below 10 mg), slower tapering at 1 mg every 4 weeks is recommended to minimize risk of adrenal insufficiency 2
- Single daily dosing is preferred over divided doses except in special situations (e.g., prominent night pain when below 5 mg daily) 2
Specific Tapering Recommendations Based on Disease Context
For Polymyalgia Rheumatica (PMR):
- Initial tapering: Reduce dose to 10 mg/day prednisone equivalent within 4-8 weeks 2
- Maintenance tapering: Once remission is achieved, taper daily oral prednisone by 1 mg every 4 weeks (or by 1.25 mg using alternate-day schedules) until discontinuation 2
- For relapse: Increase to pre-relapse dose and then gradually decrease (within 4-8 weeks) to the dose at which relapse occurred 2
For Nephrotic Syndrome:
- For children with steroid-sensitive nephrotic syndrome: After achieving remission, transition to alternate-day dosing (maximum 40 mg on alternate days) for at least 4 weeks 2
- For frequently relapsing or steroid-dependent cases: Maintain on the lowest effective alternate-day dose to prevent major adverse effects 2
For Bullous Pemphigoid:
- Initial treatment should be reduced 15 days after disease control 2
- Gradual tapering with aim of stopping treatment 4-12 months after initiation 2
Practical Tapering Schedule from 40 mg
Initial phase (first 4-8 weeks):
Slow tapering phase (below 10 mg):
Important Considerations and Precautions
- Morning dosing is preferred (before 9 am) as it aligns with the body's natural cortisol rhythm and minimizes HPA axis suppression 1
- Alternate-day therapy may be beneficial for long-term treatment to reduce adverse effects while maintaining therapeutic benefit 1
- Abrupt withdrawal should be avoided due to risk of adrenal insufficiency 1
- Patients should be monitored for signs of disease relapse during tapering 2
- For asthma exacerbations, some evidence suggests that non-tapering regimens (maintaining the same dose) may be as effective as tapering regimens with similar adrenal outcomes 3, 4
Special Situations
- For rheumatoid arthritis: Slow tapering using 1 mg decrements every 2-4 weeks is recommended, often maintaining patients on the lowest effective dose rather than complete discontinuation 5
- For sudden hearing loss: After initial high-dose treatment (60 mg daily), a representative tapering regimen uses maximum dose for 4 days, followed by a 10 mg taper every 2 days 2
- Consider steroid-sparing agents in patients who develop significant steroid-related adverse effects or who require prolonged therapy 2
Common Pitfalls to Avoid
- Tapering too quickly, especially at doses below 10 mg, which increases risk of adrenal insufficiency and disease relapse 2, 1
- Failing to monitor for signs of disease relapse during the tapering process 2
- Not providing supplemental calcium (800-1000 mg/day) and vitamin D (400-800 units/day) during prolonged steroid therapy 5
- Underdosing when switching between different corticosteroids (prednisone is 4 times more potent than hydrocortisone, methylprednisolone is 5 times more potent, and dexamethasone is 25 times more potent) 2