Prednisone Tapering Protocol for Moderate to High Dose Therapy
For patients on moderate to high dose prednisone (≥10 mg/day for >3 weeks), taper by reducing 5 mg weekly until reaching 10 mg/day, then slow to 1 mg decrements every 4 weeks until discontinuation. 1
Tapering Schedule Based on Initial Dose
High Dose (>30 mg/day)
- Reduce to 10 mg/day within 4-8 weeks 1
- Then decrease by 1 mg every 4 weeks until complete discontinuation 1
- For doses starting at 40-60 mg/day: decrease by 10 mg every 2 weeks until reaching 30 mg/day, then by 5 mg every 2 weeks until 20 mg/day, then by 2.5 mg every 2 weeks 1
- At 10 mg/day, slow to 1 mg every 2-4 weeks 1
Moderate Dose (10-30 mg/day)
- Taper by 5 mg every week until reaching 10 mg/day 1
- Then slow to 2.5 mg/week until reaching 5 mg/day 1
- Below 5 mg/day, reduce by 1 mg every 4 weeks 1
Low Dose (<10 mg/day)
- Taper by 1 mg every 4 weeks 1
- Alternative: use 1.25 mg decrements with alternate-day schedules (e.g., 10/7.5 mg alternating days) 1
Standard Short-Course Taper (2-Week Protocol)
For acute conditions requiring brief high-dose therapy:
- 60 mg daily for 4 days 2
- 40 mg daily for 3 days 2
- 30 mg daily for 3 days 2
- 20 mg daily for 3 days 2
- 10 mg daily for 3 days 2
- 5 mg daily for 3 days, then discontinue 2
Critical Timing and Administration Principles
Dosing Schedule
- Administer as single morning dose before 9 AM to minimize adrenal suppression 3
- Single daily dosing is preferred over divided doses except for prominent night pain on low doses (<5 mg daily) 4, 1
- Take with food or milk to reduce gastric irritation 3
When Tapering is Required
- Any course longer than 3 weeks requires tapering to prevent adrenal insufficiency 1
- Hypothalamic-pituitary-adrenal axis suppression should be anticipated in any patient receiving >7.5 mg daily for >3 weeks 4
Managing Relapse During Tapering
If symptoms recur during taper, return to the pre-relapse dose 1, 2
- Gradually decrease within 4-8 weeks to the dose at which relapse occurred 1
- Consider adding steroid-sparing agents if multiple relapses occur 1
- Do not attempt to push through a flare by continuing the taper 1
Adrenal Insufficiency Prevention
Stress Dosing Requirements
- Patients on chronic medium/high-dose therapy require adequate glucocorticoid replacement during acute illness or stress 4
- For patients on 10 mg prednisone daily: increase to hydrocortisone 50 mg twice daily for 3 days during acute stress 4
- For patients on high-dose therapy: hydrocortisone 50 mg three times daily during acute illness 4
Patient Education Essentials
- Educate on signs of adrenal insufficiency: fatigue, weakness, dizziness, nausea 2
- Provide instructions on stress dosing for sick days 4
- Consider medical alert bracelet for adrenal insufficiency 4
- Never stop abruptly without medical supervision 3
Evidence-Based Considerations
Rapid tapering is feasible and well-tolerated when clinically appropriate. A randomized trial in myasthenia gravis demonstrated that rapid tapering (immediate high-dose followed by early rapid decrease) achieved better outcomes than slow tapering, with 39% vs 9% reaching minimal manifestation status (RR 3.61,95% CI 1.64-7.97, P<0.001), while sparing a mean of 1898 mg prednisone over one year 5
For acute asthma exacerbations, tapering may be unnecessary after short courses. Multiple randomized trials found no difference in relapse rates or adrenal suppression between 8-day tapering courses versus non-tapering 40 mg/day courses 6, 7, 8, suggesting that tapering after brief high-dose therapy (≤10 days) provides no clinical benefit.
Common Pitfalls to Avoid
- Tapering too quickly leads to disease flare or adrenal crisis 1, 2
- Failing to slow the taper below 10 mg/day (this is where adrenal recovery becomes critical) 1
- Not monitoring for steroid-related complications during prolonged tapers 1
- Attempting to taper during active disease flare 1
- Discontinuing abruptly after >3 weeks of therapy 1, 3