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

Prednisone Tapering Recommendations

The optimal prednisone tapering schedule should be based on initial dose, duration of therapy, 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

• Prednisone tapering should be individualized based on disease activity, laboratory markers, and adverse events 1
• Single daily dosing is preferred over divided doses except for special situations such as prominent night pain while on low doses (<5 mg daily) 1, 2
• For courses longer than 3 weeks, tapering is necessary to prevent adrenal insufficiency 1, 3
• Morning administration (before 9 am) is recommended to minimize adrenal suppression, as this coincides with the natural peak of adrenal cortex activity 3

Specific Tapering Schedules by Initial Dose

For High Initial Doses (>30 mg/day)

• Reduce the dose to 10 mg/day within 4-8 weeks 1, 2
• Then reduce by 1 mg every 4 weeks until discontinuation 1
• High doses should be avoided unless absolutely necessary for the specific condition 1

For 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
• Below 5 mg/day, taper by 1 mg every 2-4 weeks 2

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) 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 Inflammatory Myopathies

• Initial dose: 0.5-1 mg/kg/day (typically 60-80 mg/day) 2
• Taper by 10 mg every 2 weeks until reaching 30 mg/day 2
• Then taper by 5 mg every 2 weeks until reaching 20 mg/day 2
• Then taper by 2.5 mg every 2 weeks until reaching 10 mg/day 2
• At 10 mg/day, slow to 1 mg every 2-4 weeks until completed 2

For Rheumatoid Arthritis

• Treatment should not exceed 10 mg/day 4
• Tapering should be done slowly using 1 mg decrements every 2-4 weeks 1, 4

For Immune-Related Adverse Events

• Start with 0.5-1 mg/kg/day for grade 2 events and 1-2 mg/kg/day for grade 3-4 events 1, 2
• Once symptoms improve to grade 1, taper over 4-6 weeks 1, 2

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

Alternate Day Therapy

• Alternate day therapy (twice the usual daily dose every other morning) may be considered for long-term treatment to minimize side effects 3
• This approach helps reduce pituitary-adrenal suppression, cushingoid state, withdrawal symptoms, and growth suppression in children 3

Adrenal Insufficiency Prevention

• Drug-induced adrenocortical insufficiency may persist for up to 12 months after discontinuation of long-term therapy 3
• In situations of stress during this period, hormone therapy should be reinstituted 3
• Patients should be warned not to discontinue corticosteroids abruptly or without medical supervision 3

Common Pitfalls to Avoid

• Tapering too quickly, which may lead to disease flare or adrenal insufficiency 1, 3
• Using high initial doses (>30 mg/day) without clear indication 1
• Not providing patients with clear instructions about the tapering schedule 1, 3
• Failing to monitor for steroid-related side effects during tapering 2
• Not considering bone health - calcium (800-1,000 mg/day) and vitamin D (400-800 units/day) supplementation should be initiated with treatment 4