What is the recommended dosage and tapering schedule for prednisolone (corticosteroid) in the management of pure neuritic leprosy?

Steroid Dosage and Tapering in Pure Neuritic Leprosy

For pure neuritic leprosy, initiate prednisolone at 40 mg daily (or 1 mg/kg/day) alongside multidrug therapy, maintain this dose for 12 weeks, then taper by 5 mg every 2 weeks over the subsequent 8 weeks, completing treatment by 20 weeks. 1

Initial Dosing Strategy

Start prednisolone at 40 mg daily (approximately 1 mg/kg/day) at the time of diagnosis, given concurrently with standard multibacillary multidrug therapy (MB-MDT). 2, 1 This dosing applies whether the patient presents with acute neuritis, type 1 or type 2 reactions, or silent neuropathy. 2

• Higher initial doses (2 mg/kg/day) show better results only in the first month, but early treatment with 1 mg/kg/day proves equally effective by 6 months. 1
• The 40 mg daily dose represents the standard therapeutic approach for leprosy neuropathy with established nerve function impairment. 2

Maintenance Phase

Continue the full 40 mg daily dose for 12 weeks (3 months) without reduction. 2, 3 This duration is critical for adequate disease control before initiating any taper.

• Prophylactic prednisolone at 20 mg daily for 3 months shows significant benefit in preventing nerve function impairment at 4 months, though this effect diminishes by 12 months. 3
• For established neuritic leprosy (not prophylaxis), the higher 40 mg dose for the full 12 weeks is necessary given that nerve damage is already present. 2

Tapering Schedule

After 12 weeks at 40 mg daily, begin tapering by 5 mg every 2 weeks:

• Week 12-14: 35 mg daily
• Week 14-16: 30 mg daily
• Week 16-18: 25 mg daily
• Week 18-20: 20 mg daily
• Complete taper by week 20 (5 months total duration) 4

This structured taper prevents disease rebound while minimizing long-term steroid exposure. 4

Duration Considerations

Total treatment duration should be at least 5 months (20 weeks), with some evidence supporting extension to 8 months in multibacillary cases. 4

• A study using prophylactic prednisolone 20 mg daily for 6 months followed by tapering over months 7-8 showed significantly better prevention of nerve function deterioration compared to MDT alone. 4
• For pure neuritic leprosy with established impairment, the 5-month regimen (12 weeks full dose + 8 weeks taper) represents the minimum effective duration. 2, 1

Type 2 Reactions

In type 2 reactions (erythema nodosum leprosum), shorter steroid courses are effective: Start at 1 mg/kg/day and taper to 0.5 mg/kg/day or less within one month. 1 This differs from the longer course needed for type 1 reactions and pure neuritic presentations.

Critical Monitoring Points

Assess nerve function at baseline, 8 weeks, 12 weeks (before taper), and at completion of therapy using:

• Monofilament testing for sensory function
• Voluntary muscle testing for motor function
• Nerve palpation for tenderness
• Nerve conduction studies when available (most sensitive for detecting subclinical involvement) 2

Nearly all multibacillary patients show peripheral nerve abnormalities on nerve conduction studies regardless of clinical presentation, emphasizing the importance of early aggressive treatment. 2

Common Pitfalls

• Avoid premature tapering: Beginning taper before 12 weeks risks inadequate disease control and rebound nerve damage. 2, 1
• Don't use prophylactic doses for established disease: The 20 mg prophylactic dose is insufficient for patients presenting with nerve function impairment; use 40 mg instead. 2, 3
• Recognize that lower doses work if started early: If treatment begins immediately at diagnosis, 1 mg/kg/day is as effective as 2 mg/kg/day by 6 months, but delays necessitate higher doses. 1
• Monitor for steroid-related complications: Given the 5-8 month duration, assess for hyperglycemia, hypertension, weight gain, and bone density loss throughout treatment. 5

Adjunctive Measures

Combine corticosteroids with:

• Standard MB-MDT for 12 months minimum 4, 6
• Pain management strategies 6
• Physiotherapy to prevent contractures 6
• Self-care education for insensate limbs 6

High-resolution ultrasonography can objectively document nerve thickening and monitor treatment response, though clinical assessment remains the primary guide. 6