Prednisone Tapering After 12 Weeks at 20 mg Daily
For a patient on 20 mg prednisone daily for 12 weeks, taper down to physiological doses (5-10 mg) over 5-10 days, then continue a slower taper over an additional 1-2 weeks to minimize adrenal insufficiency risk while monitoring for withdrawal symptoms. 1
Tapering Strategy
Initial Rapid Taper Phase (Supraphysiological Range)
- Reduce from 20 mg to 10 mg over 5-10 days 1
- This initial phase can proceed more quickly since the dose remains above physiological replacement levels 2
- The guideline evidence for immune-related adverse events specifically recommends tapering stress-dose corticosteroids (20 mg prednisone) down to maintenance doses over 5-10 days 1
Slower Taper Phase (Physiological Range)
- Once at 5-10 mg daily, taper more slowly over an additional 1-2 weeks 1, 3
- At physiological doses, the hypothalamic-pituitary-adrenal (HPA) axis recovery becomes the limiting factor 4, 2
- Any patient receiving ≥20 mg prednisone daily for more than 5 days is at risk for HPA suppression 5
Critical Monitoring Considerations
Adrenal Insufficiency Risk
- HPA axis suppression should be anticipated after 12 weeks at 20 mg daily 1, 5
- Recovery from this duration of exposure may take weeks to months after complete cessation 5, 4
- Patients require education on stress dosing and should carry medical alert identification 1
Distinguishing Withdrawal Syndrome from Adrenal Insufficiency
- Glucocorticoid withdrawal syndrome causes symptoms despite adequate adrenal function 4
- If symptoms prevent tapering, perform morning cortisol testing (ideally 09:00h cortisol) 6
- A morning cortisol >350 nmol/L suggests adequate adrenal function 6
- Consider short synacthen test if morning cortisol is <350 nmol/L and clinical uncertainty exists 6
Practical Tapering Schedule Example
Week 1-2: 20 mg → 15 mg daily 1
Week 2-3: 15 mg → 10 mg daily 1
Week 3-4: 10 mg → 7.5 mg daily 1, 3
Week 4-5: 7.5 mg → 5 mg daily 1, 3
Week 5+: Consider stopping or continuing at 5 mg if symptoms suggest adrenal insufficiency 1, 4
Important Caveats
Stress Dosing During Taper
- Increase glucocorticoid dose during intercurrent illness or stress 1
- For minor illness: double the current dose for 3 days 1
- For major stress/surgery: may require hydrocortisone 50-100 mg IV depending on severity 1
Individual Variation
- The current prednisone dose at time of assessment is the strongest predictor of adrenal insufficiency risk 6
- Peak historical dose (not duration) predicts recovery likelihood 6
- Recovery is spontaneous and time-dependent once tapering begins 5, 4
Bone Protection
- Initiate calcium and vitamin D supplementation 1
- Consider bone density screening given the 12-week exposure at 20 mg daily 1
When to Maintain Low-Dose Therapy
- If symptoms of adrenal insufficiency persist at 5 mg daily despite slow tapering, the patient may require ongoing physiological replacement (5-10 mg prednisone daily) until HPA axis recovery occurs 1, 4
- This replacement may be needed for months, as recovery from 12 weeks of supraphysiological dosing is highly variable 5, 2