What is the recommended protocol for a prednisone (corticosteroid) taper?

Prednisone Tapering Protocol

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 of Prednisone Tapering

• 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, 2
• For courses longer than 3 weeks, tapering is necessary to prevent adrenal insufficiency 1, 3
• Morning administration (before 9 am) is recommended to minimize adrenal suppression by aligning with the body's natural cortisol rhythm 3

Specific Tapering Schedules by Initial Dose

For High Initial Doses (>30 mg/day)

• Reduce to 10 mg/day within 4-8 weeks 1, 2
• Then taper by 1 mg every 4 weeks until discontinuation 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
• Below 5 mg/day, reduce by 1 mg every 4 weeks 1

For Short Courses (≤2 weeks)

• A standard 2-week taper starts with 40 mg daily for 3-4 days, then reduces by 5 mg every 2-3 days until completion 4
• For asthma exacerbations, evidence suggests that a non-tapering course may be as effective as a tapering course 5

Disease-Specific Recommendations

For Polymyalgia Rheumatica

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

For Giant Cell Arteritis

• Initial dose: 40-60 mg/day 6
• Taper to 15-20 mg/day within 2-3 months 6
• Then taper to ≤5 mg/day after 1 year 6

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 reaching 10 mg/day 1
• At 10 mg/day, slow to 1 mg every 2-4 weeks until completed 1

For Rheumatoid Arthritis

• Low-dose prednisone (≤10 mg/day) is effective and should be tapered slowly using 1 mg decrements every 2-4 weeks 7

Managing Relapse During Tapering

• If relapse occurs, return to the pre-relapse dose 1, 2
• Gradually decrease within 4-8 weeks to the dose at which relapse occurred 1, 2
• Consider adding steroid-sparing agents if multiple relapses occur 1, 2

Special Considerations

• For patients with diabetes, more frequent blood glucose monitoring is recommended during the taper 4
• Calcium (800-1000 mg/day) and vitamin D (400-800 units/day) supplementation should be initiated with prednisone treatment to prevent bone loss 1, 7
• Patients should be warned not to discontinue prednisone abruptly as this may cause adrenal insufficiency 3
• Monitor for signs of adrenal insufficiency during tapering (fatigue, weakness, dizziness, nausea) 4

Common Pitfalls to Avoid

• Tapering too quickly can lead to disease flare or adrenal insufficiency 1, 4
• Using doses >30 mg/day for extended periods significantly increases risk of adverse effects without proportional therapeutic benefit 2
• Not providing patients with clear instructions about the tapering schedule can lead to non-adherence 4
• Failing to monitor for steroid-related side effects during tapering 1
• Individuals who have received 1-4 weeks of suppressive steroid treatment should be considered at risk for HPA axis suppression during stressful situations for up to one year 8