Recommended Prednisone Tapering Schedule
For prednisone tapering, the optimal approach is to gradually reduce the dose to 10 mg/day within 4-8 weeks, then reduce by 1 mg every 4 weeks until discontinuation. 1, 2
General Principles of Prednisone Tapering
- Single daily dosing is preferred over divided doses to minimize adrenal suppression, except in special situations such as prominent night pain while on low doses (<5 mg daily) 3, 1
- For courses longer than 3 weeks, tapering is necessary to prevent adrenal insufficiency 2, 4
- If the drug is to be stopped after long-term therapy, it should be withdrawn gradually rather than abruptly 4
Specific Tapering Schedules Based on Initial Dose
For High Initial Doses (>30 mg/day)
- Reduce the dose to 10 mg/day within 4-8 weeks 1, 2
- Then taper by 1 mg every 4 weeks until discontinuation 1
- The European League Against Rheumatism strongly recommends against high doses (>30 mg/day) unless absolutely necessary due to increased risk of adverse effects 3, 5
For Medium Initial Doses (10-30 mg/day)
- Taper by 5 mg every week until reaching 10 mg/day 2
- Then slow the taper to 2.5 mg/week until reaching 5 mg/day 2
- For polymyalgia rheumatica, an initial dose of 12.5-25 mg prednisone equivalent daily is recommended, with initial tapering to 10 mg/day within 4-8 weeks 3
For Low Doses (<10 mg/day)
- Taper by 1 mg every 4 weeks 1, 2
- Alternative approach: Use 1.25 mg decrements with alternate-day schedules (e.g., 10/7.5 mg alternate days) 3
- For doses below 5 mg/day, consider split dosing if night pain becomes prominent 3, 5
Managing Relapse During Tapering
- If relapse occurs, return to the pre-relapse dose 3, 2
- Then 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, 2
Alternative Tapering Methods
- For patients who might benefit from lower cumulative glucocorticoid doses, intramuscular methylprednisolone can be considered as an alternative to oral glucocorticoids 3
- In one clinical trial, i.m. methylprednisolone was applied at a dose of 120 mg every 3 weeks until week 9, then 100 mg at week 12, followed by monthly injections with dose reduced by 20 mg every 12 weeks until week 48, and then by 20 mg every 16 weeks until discontinuation 3
Special Considerations
- The FDA label notes that if after a reasonable period there is a lack of satisfactory clinical response, prednisone should be discontinued and the patient transferred to other appropriate therapy 4
- Alternate day therapy (giving twice the usual daily dose every other morning) may be considered for long-term treatment to minimize certain undesirable effects 4
- For short courses of prednisone (less than 3 weeks), tapering may not be necessary, as demonstrated in studies of asthma exacerbations 6, 7
Common Pitfalls to Avoid
- Tapering too quickly can lead to disease flare or adrenal insufficiency 2, 4
- Using high doses (>30 mg/day) for extended periods significantly increases risk of adverse effects without proportional therapeutic benefit 3, 5
- Not providing patients with clear instructions about the tapering schedule 2
- Failing to monitor for steroid-related side effects during tapering 1