Tapering 40mg Prednisone: Recommended Schedule
For most conditions requiring 40mg prednisone, reduce the dose to 10mg daily within 4-8 weeks, then taper by 1mg every 4 weeks until discontinuation. 1, 2
Initial Rapid Taper Phase (Weeks 1-8)
Reduce from 40mg to 10mg over 4-8 weeks using the following approach: 3, 1, 2
- Decrease by 5mg every 1-2 weeks until reaching 10mg daily 2
- Administer as a single morning dose before 9am to minimize adrenal suppression 4
- Monitor for disease flare and adverse effects every 4-8 weeks during this phase 3, 1
This initial rapid taper is supported by the European League Against Rheumatism guidelines for multiple rheumatic conditions and represents the standard approach across disease states. 3, 1
Maintenance Taper Phase (After Week 8)
Once at 10mg daily, slow the taper to 1mg decrements every 4 weeks until complete discontinuation: 3, 1, 2
- This slower taper minimizes risk of adrenal insufficiency and disease relapse 2
- Continue single morning dosing 4
- Follow-up every 8-12 weeks during this phase 3, 1
The European League Against Rheumatism emphasizes this slower taper at lower doses is critical, as the adrenal axis becomes increasingly vulnerable below 10mg daily. 3, 2
Special Considerations for Doses Below 5mg
If night pain or breakthrough symptoms occur below 5mg daily, consider split dosing (e.g., morning and evening doses): 3, 1
- However, persistent symptoms should prompt reconsideration of the diagnosis 3
- Split dosing increases adrenal suppression risk but may be necessary for symptom control 3, 1
Managing Relapse During Taper
If disease flares during tapering, increase back to the pre-relapse dose, then: 3, 1
- Gradually decrease within 4-8 weeks to the dose where relapse occurred 3, 1
- Hold at that dose longer before attempting further reduction 3
- Consider adding steroid-sparing agents (e.g., methotrexate 7.5-10mg weekly) if multiple relapses occur 3, 1
Duration of Therapy
Total treatment duration typically ranges 4-12 months depending on the underlying condition: 3, 2
- Polymyalgia rheumatica often requires 12+ months 3
- Bullous pemphigoid typically needs 4-12 months 3, 2
- Acute conditions may require shorter courses 2
Short-Course Exception (≤2 Weeks)
For acute conditions treated with 40mg for only 1-2 weeks, tapering may not be necessary: 5, 6, 7
- Research shows no difference in relapse rates between tapered and non-tapered short courses 5, 6
- No adrenal suppression was demonstrated after 8-day courses 5
- However, the FDA label recommends gradual withdrawal after long-term therapy 4
Critical Pitfalls to Avoid
Never taper faster than 1mg every 4 weeks below 10mg daily - this dramatically increases adrenal crisis risk and disease relapse: 1, 2
- Tapering too quickly at low doses is the most common error 2
- Failing to monitor for relapse during tapering leads to delayed recognition of flares 1, 2
- Abrupt discontinuation after prolonged therapy can precipitate adrenal crisis 4
Do not use divided doses unless specifically indicated (e.g., breakthrough symptoms <5mg), as this increases HPA axis suppression: 4, 7
Monitoring Requirements
Assess clinical response and inflammatory markers at regular intervals: 3, 1
- Every 4-8 weeks during first year 3, 1
- Every 8-12 weeks during second year 3, 1
- More frequently if symptoms suggest relapse 3, 1
Initiate osteoporosis prophylaxis if treatment expected >3 months: 3