What is the recommended length and tapering regimen of prednisone (corticosteroid) in minimal change disease?

Prednisone Treatment Regimen for Minimal Change Disease

For adults with minimal change disease (MCD), prednisone should be given at a daily single dose of 1 mg/kg (maximum 80 mg) for a minimum of 4 weeks if complete remission is achieved, and tapered slowly over a total period of up to 6 months after achieving remission. 1

Initial Treatment Dosing

• Prednisone or prednisolone should be administered as a single daily dose of 1 mg/kg (maximum 80 mg) or as an alternate-day single dose of 2 mg/kg (maximum 120 mg) 1
• The initial high dose should be maintained for a minimum period of 4 weeks if complete remission is achieved 1
• If complete remission is not achieved within 4 weeks, the high dose can be continued for a maximum period of 16 weeks 1
• Response to treatment in adults may take up to 16 weeks, compared to an average of 11 days in children 2

Tapering Schedule

• After achieving remission, prednisone should be tapered slowly over a total period of up to 6 months 1
• A structured tapering approach helps prevent rebound symptoms and minimizes the risk of adrenal insufficiency 3
• For MCD patients who have achieved remission, a gradual reduction to 10 mg/day within 4-8 weeks is recommended, followed by reducing by 1 mg every 4 weeks until discontinuation 4
• Single daily dosing is preferred over divided doses to minimize adrenal suppression 4

Treatment of Relapses

• For infrequent relapses, the same initial dose and duration of corticosteroids should be used as for the first episode 1
• For patients with frequent relapses, daily prednisone should be given until remission (at least 3 days), followed by alternate-day prednisone for at least 3 months 1
• In adults with MCD who have relapsed after achieving complete remission with prednisone dose <10 mg/day, increasing the dose to 10-20 mg/day appears to be as effective as higher doses (>20 mg/day) for treating the relapse 5

Special Considerations

• For patients with relative contraindications or intolerance to high-dose corticosteroids (e.g., uncontrolled diabetes, psychiatric conditions, severe osteoporosis), oral cyclophosphamide or calcineurin inhibitors should be considered 1
• Acute kidney injury (AKI) in the setting of newly diagnosed MCD should be treated with renal replacement therapy as indicated, along with corticosteroids as for a first episode 1
• For the initial episode of nephrotic syndrome associated with MCD, statins are not recommended to treat hyperlipidemia, and ACE inhibitors or ARBs are not recommended in normotensive patients to lower proteinuria 1

Monitoring During Treatment

• Monitor for steroid-related side effects during treatment and tapering 4
• If symptoms recur during tapering, return to the pre-relapse dose and decrease more gradually (within 4-8 weeks) to the dose at which the relapse occurred 4
• Watch for signs of adrenal insufficiency during tapering (fatigue, weakness, dizziness, nausea) 3
• For patients with diabetes, more frequent blood glucose monitoring is recommended during the taper 3

Common Pitfalls to Avoid

• Tapering too quickly, which may lead to disease flare or adrenal insufficiency 3, 4
• Not providing patients with clear instructions about the tapering schedule 3
• Prolonged high-dose corticosteroid therapy without considering steroid-sparing agents in patients with frequent relapses or steroid dependence 1