Steroid Taper and Insulin Management Plan for Patient on Prednisone
For a patient on 60mg prednisone with 12 units NPH and 21 units lispro insulin, I recommend tapering the prednisone by 10mg weekly while adjusting insulin doses proportionally to the steroid reduction. 1, 2
Prednisone Tapering Schedule
Week 1: 60mg prednisone daily
Week 2: 50mg prednisone daily
Week 3: 40mg prednisone daily
Week 4: 30mg prednisone daily
Week 5: 20mg prednisone daily
Week 6: 10mg prednisone daily
Secondary Tapering Phase (Once at 10mg/day)
Week 7: 7.5mg prednisone daily
- NPH: 1-2 units
- Lispro: 2-3 units 1
Week 8: 5mg prednisone daily
- NPH: 0-1 units
- Lispro: 0-2 units (based on blood glucose monitoring) 1
Week 9: 2.5mg prednisone daily
- Discontinue NPH if not already done
- Lispro: as needed based on blood glucose 1
Week 10: Discontinue prednisone
- Monitor blood glucose and adjust insulin as needed 1
Rationale and Monitoring
The American Association for the Study of Liver Diseases recommends reducing prednisone by 5-10mg weekly until reaching 10mg/day, then slowing to 2.5mg reductions weekly 1
Administer prednisone as a single morning dose (before 9am) to minimize adrenal suppression and align with the body's natural cortisol rhythm 3
Insulin requirements typically decrease proportionally with steroid reduction, requiring approximately 20% reduction in insulin dose for each 10mg reduction in prednisone 2, 4
Monitor blood glucose 4 times daily (fasting, pre-lunch, pre-dinner, bedtime) and adjust insulin doses as needed 3, 4
Insulin lispro (rapid-acting) is particularly useful for managing steroid-induced hyperglycemia due to its quick onset and shorter duration of action 4
Important Considerations
Patients should be monitored for signs of adrenal insufficiency during tapering, including fatigue, weakness, dizziness, nausea, and hypotension 1, 3
If the patient experiences disease flare during tapering, return to the previous effective dose and attempt a slower taper (5mg every 2 weeks) 1, 2
Insulin lispro should be drawn into the syringe first if mixing with NPH insulin, and injected immediately after mixing 4
Consider calcium and vitamin D supplementation during the steroid taper to prevent osteoporosis 1, 2
For stress situations (illness, surgery), temporary increase in steroid dose may be necessary 1
Follow-up visits should occur every 1-2 weeks during the taper to assess response and adjust medications as needed 1, 3