Prednisone Tapering Protocol for 20 mg Daily Dose After 6 Months of Treatment
For a patient who has been taking 20 mg of prednisone daily for 6 months, the optimal tapering schedule involves gradually reducing the dose to 10 mg/day within 4-8 weeks, then reducing by 2.5 mg every 2 weeks until reaching 5 mg/day, followed by a slower taper of 1 mg every 2-4 weeks until discontinuation. 1
Initial Tapering Phase (20 mg to 10 mg)
- Reduce prednisone by 5 mg every 1-2 weeks until reaching 10 mg/day 2, 1
- For example:
- Weeks 1-2: 15 mg/day
- Weeks 3-4: 10 mg/day
Intermediate Tapering Phase (10 mg to 5 mg)
- Once at 10 mg/day, slow the taper to 2.5 mg decrements every 2 weeks 1, 3
- For example:
- Weeks 5-6: 7.5 mg/day
- Weeks 7-8: 5 mg/day
Final Tapering Phase (Below 5 mg)
- At 5 mg/day, further slow the taper to 1 mg decrements every 2-4 weeks until complete discontinuation 2, 1
- For example:
- Weeks 9-12: 4 mg/day
- Weeks 13-16: 3 mg/day
- Weeks 17-20: 2 mg/day
- Weeks 21-24: 1 mg/day
- Week 25: Discontinue
Rationale and Evidence
This tapering schedule is designed to minimize the risk of adrenal insufficiency while gradually withdrawing corticosteroid therapy. After 6 months of continuous prednisone at 20 mg/day, the hypothalamic-pituitary-adrenal (HPA) axis is likely suppressed, requiring a careful taper 4.
The FDA drug label for prednisone emphasizes that "if after long-term therapy the drug is to be stopped, it is recommended that it be withdrawn gradually rather than abruptly" 4. This is particularly important after 6 months of therapy, as abrupt withdrawal could lead to adrenal crisis.
Special Considerations
Monitoring During Tapering
- Watch for signs of disease relapse during tapering, which may necessitate temporarily returning to a higher dose 3
- Monitor for symptoms of adrenal insufficiency (fatigue, weakness, nausea, hypotension) 5
- Consider morning cortisol levels if symptoms of adrenal insufficiency develop 1
Alternative Approaches
- For patients with severe steroid-related side effects, consider a more aggressive taper with close monitoring 2
- For patients at high risk of disease relapse, consider a slower taper, particularly in the final phase 1, 3
- For patients with significant night symptoms, consider split dosing rather than increasing the total daily dose when on low doses (<5 mg daily) 3
Common Pitfalls to Avoid
- Tapering too quickly, which may precipitate disease flare or adrenal insufficiency 1
- Failing to monitor for steroid-related side effects during the tapering process 2
- Not providing patients with clear instructions about the tapering schedule 5
- Abrupt discontinuation of therapy, which can lead to adrenal crisis 4
Disease-Specific Considerations
If the prednisone was prescribed for a specific condition, the tapering schedule might need adjustment:
- For autoimmune hepatitis: Once at 20 mg/day, taper by 5 mg every week until reaching 10 mg/day, then by 2.5 mg/week until 5 mg/day is reached 2
- For inflammatory myopathies: 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 until completed 2
- For bullous pemphigoid: Aim to reach minimal therapy (prednisone 0.1 mg/kg/day) within 4-6 months of initiation of treatment 2
This tapering protocol balances the need to minimize the risk of disease relapse while reducing the likelihood of steroid-related adverse effects and adrenal insufficiency.