What is the recommended taper schedule for prednisone (corticosteroid)?

Prednisone Tapering Recommendations

The optimal prednisone taper involves gradually reducing the dose to 10 mg/day within 4-8 weeks, then reducing by 1 mg every 4 weeks until discontinuation. 1

General Principles

• Prednisone tapering should be individualized based on disease activity, laboratory markers, and adverse events 1
• Single daily dosing is preferred over divided doses except in special situations such as prominent night pain while on low doses (<5 mg daily) 2
• 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)

• Reduce dose to 10 mg/day within 4-8 weeks 1
• Then reduce by 1 mg every 4 weeks until discontinuation 2
• High doses (>30 mg/day) are strongly discouraged unless absolutely necessary for the specific condition 2

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
• Further taper by 1 mg every 4 weeks until discontinuation 2

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) 2

Disease-Specific Recommendations

For Autoimmune Hepatitis

• For adults: From 20 mg daily, reduce by 5 mg every week until 10 mg/day, then further reduction by 2.5 mg/week until 5 mg daily 2
• 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 2

For Polymyalgia Rheumatica

• Initial dose: 12.5-25 mg prednisone equivalent daily 2
• Initial tapering: Reduce to 10 mg/day within 4-8 weeks 2
• Maintenance tapering: Reduce by 1 mg every 4 weeks until discontinuation 2

For Immune-Related Adverse Events

• For grade 2 events: Start with 0.5-1 mg/kg/day until symptoms improve to grade 1 2
• For grade 3-4 events: Start with 1-2 mg/kg/day until symptoms improve to grade 1 2
• Then taper over 4-6 weeks 2

Managing Relapse During Tapering

• Return to the pre-relapse dose if symptoms recur 2
• Gradually decrease within 4-8 weeks to the dose at which relapse occurred 2
• Consider adding steroid-sparing agents if multiple relapses occur 2

Special Considerations

For Short-Term Use

• For acute asthma exacerbations, some evidence suggests that a short course without tapering may be as effective as a tapered course 3, 4
• However, for most conditions requiring more than 3 weeks of treatment, tapering is necessary to prevent adrenal insufficiency 1

For Rheumatoid Arthritis

• Low doses (≤10 mg/day) are effective and should be tapered slowly using 1 mg decrements every 2-4 weeks 5
• Consider divided doses (e.g., 5 mg twice daily) for better control of inflammation 5

Common Pitfalls to Avoid

• Tapering too quickly, which may lead to disease flare or adrenal insufficiency 1
• Using high initial doses (>30 mg/day) without clear indication 2
• Failing to provide calcium (800-1000 mg/day) and vitamin D (400-800 units/day) supplementation during treatment 5
• Not providing patients with clear instructions about tapering schedule 1

Algorithm for Prednisone Tapering

1. Determine initial dose based on disease severity and patient factors
2. For doses >10 mg/day:
   • Reduce by 5 mg every 1-2 weeks until reaching 10 mg/day 1
3. For doses ≤10 mg/day:
   • Slow taper to 1 mg every 4 weeks 2
   • Or use alternate-day dosing (e.g., 10/7.5 mg) 2
4. Monitor for disease activity and adverse events throughout taper 1
5. If relapse occurs:
   • Return to pre-relapse dose 2
   • Once controlled, resume taper more gradually 2