What is the recommended taper schedule for prednisone (corticosteroid)?

Prednisone Tapering Recommendations

Prednisone tapering should be individualized based on initial dose, duration of treatment, and underlying condition, with high doses (>30 mg/day) reduced to 10 mg/day within 4-8 weeks, then by 1 mg every 4 weeks until discontinuation. 1, 2

General Principles

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

Specific Tapering Schedules by Initial Dose

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

Medium Initial Doses (10-30 mg/day)

• Taper by 5 mg every week until reaching 10 mg/day 1, 2
• Then slow the taper to 2.5 mg/week until reaching 5 mg/day 1, 2
• At 5 mg/day, further reduce by 1 mg every 2-4 weeks 2

Low Initial 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) 2

Disease-Specific Recommendations

For Polymyalgia Rheumatica

• Initial dose: 12.5-25 mg prednisone equivalent daily 1, 2
• Initial tapering: Reduce to 10 mg/day within 4-8 weeks 1, 2
• Maintenance tapering: Reduce by 1 mg every 4 weeks until discontinuation 1, 2

For Rheumatoid Arthritis

• Daily doses should not exceed 10 mg/day 4
• Tapering should be done slowly using 1 mg decrements every 2-4 weeks 1, 4
• Consider divided doses (e.g., 5 mg twice daily) if needed for symptom control 4

For Autoimmune Hepatitis

• For adults: Reduce by 5 mg every week until 10 mg/day, then further reduction by 2.5 mg/week until 5 mg daily 1
• For children: Start with 1-2 mg/kg/day (up to 60 mg/day), taper over 6-8 weeks to 0.1-0.2 mg/kg daily or 5 mg daily 2

For Myasthenia Gravis

• Evidence suggests that a rapid tapering regimen may be more effective than slow tapering 5
• Rapid tapering (starting at 0.75 mg/kg/day with earlier decrease once improved) showed better outcomes than slow tapering in patients also receiving azathioprine 5

Managing Relapse During Tapering

• If symptoms recur during tapering, return to the pre-relapse dose 1, 2
• Then 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 asthma exacerbations, evidence suggests that an abrupt discontinuation after a short course (7-10 days) may be as effective as tapering, with no difference in relapse rates or adrenal suppression 6, 7
• Alternate day therapy (twice the usual daily dose administered every other morning) may help minimize pituitary-adrenal suppression and other side effects during long-term treatment 3
• Calcium (800-1,000 mg/day) and vitamin D (400-800 units/day) supplementation should be initiated with prednisone treatment to prevent bone loss 4

Common Pitfalls to Avoid

• Tapering too quickly, which may lead to disease flare or adrenal insufficiency 1
• Using high initial doses (>30 mg/day) without clear indication 1
• Failing to provide patients with clear instructions about the tapering schedule 1, 2
• Abrupt withdrawal of therapy after long-term use, which can precipitate adrenal crisis 3