Prednisone Tapering Schedule
The optimal prednisone taper involves gradually reducing the dose to 10 mg/day within 4-8 weeks, then reducing by 1 mg every 4 weeks until discontinuation. 1
General Principles
- 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
- For courses longer than 3 weeks, tapering is necessary to prevent adrenal insufficiency 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 Based on Initial Dose
For High Initial Doses (>30 mg/day)
- Reduce the dose to 10 mg/day within 4-8 weeks 1
- Then reduce by 1 mg every 4 weeks until discontinuation 1
- For inflammatory conditions: Start with prednisone 20 mg daily for 2-4 weeks, then taper over 4-8 weeks 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
- At 5 mg/day, further slow the taper to 1 mg decrements 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) 1
Disease-Specific Recommendations
For Autoimmune Hepatitis
- For adults: Start with prednisone 30 mg/day, taper to 10 mg/day for maintenance 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 4
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) 1
- Taper by 10 mg every 2 weeks until reaching 30 mg/day 1
- Then taper by 5 mg every 2 weeks until reaching 20 mg/day 1
- Then taper by 2.5 mg every 2 weeks until reaching 10 mg/day 1
- At 10 mg/day, slow to 1 mg every 2-4 weeks until completed 1
Managing Relapse During Tapering
- Return to the pre-relapse dose if symptoms recur 1, 2
- 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
Alternate Day Therapy
- Alternate day therapy involves administering twice the usual daily dose every other morning 3
- This approach helps minimize pituitary-adrenal suppression while maintaining therapeutic effects 3
- The rationale is based on the fact that anti-inflammatory effects persist longer than metabolic effects, and the off-day allows for more normal hypothalamic-pituitary-adrenal activity 3
Common Pitfalls to Avoid
- Tapering too quickly, which may lead to disease flare or adrenal insufficiency 1, 2
- Not providing patients with clear instructions about tapering schedule 2
- Failing to monitor for steroid-related side effects during tapering 1
- Abrupt withdrawal of therapy, which should be avoided as stated in the FDA label 3
Evidence on Tapering vs. Non-Tapering
- For acute asthma exacerbations, studies have shown no significant difference in relapse rates or adrenal suppression between patients receiving an 8-day tapering course versus a fixed 8-day course of 40 mg/day 5, 6, 7
- For rheumatoid arthritis patients on tocilizumab, continuing low-dose prednisone (5 mg/day) provided better disease control than tapering, although two-thirds of patients were able to safely taper their glucocorticoid dose 8