Prednisone Tapering Recommendations
The optimal prednisone tapering schedule involves reducing the dose to 10 mg/day within 4-8 weeks, followed by a slow taper of 1 mg every 4 weeks until discontinuation. 1
General Principles
- Prednisone tapering should be individualized based on disease activity, laboratory markers, and potential adverse events 1
- Single daily dosing is preferred over divided doses to minimize adrenal suppression 1, 2
- For courses longer than 3 weeks, tapering is necessary to prevent adrenal insufficiency 1
- Morning administration (before 9 am) is recommended to align with the body's natural cortisol rhythm 2
Specific Tapering Schedules by Initial Dose
For High Initial Doses (>30 mg/day)
- Reduce to 10 mg/day within 4-8 weeks 3, 1
- Then taper by 1 mg every 4 weeks until discontinuation 1
- Alternative approach: Decrease by 5 mg every week until reaching 10 mg/day 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 3, 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 3, 1
- Initial tapering: Reduce to 10 mg/day within 4-8 weeks 3, 1
- Maintenance tapering: Reduce by 1 mg every 4 weeks until discontinuation 3, 1
- Some evidence suggests that a rapid taper to 5 mg/day followed by a year at this dose before further tapering may result in lower total prednisone exposure 4
For Inflammatory Conditions
- Initial dose varies by condition (typically 0.5-1 mg/kg/day) 1
- For severe conditions: Taper by 10 mg every 2 weeks until reaching 30 mg/day, then by 5 mg every 2 weeks until reaching 20 mg/day, then by 2.5 mg every 2 weeks 1
- At 10 mg/day, slow to 1 mg every 2-4 weeks until completed 1
Managing Relapse During Tapering
- Return to the pre-relapse dose that effectively controlled symptoms 3, 5
- Gradually decrease within 4-8 weeks to the dose at which relapse occurred 3, 5
- Consider adding steroid-sparing agents if multiple relapses occur 5
Special Considerations
- For night pain while tapering below 5 mg daily, split doses may be considered 3, 1
- If withdrawing after long-term therapy, taper gradually rather than abruptly 2
- Alternate-day therapy (twice the usual daily dose every other morning) may help minimize adrenal suppression during long-term treatment 2
- Monitor for signs of adrenal insufficiency during tapering 1
Common Pitfalls to Avoid
- 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 1
- Continuing treatment without considering steroid-sparing agents in patients requiring prolonged therapy 5