What is the best approach to taper a patient off prednisone (corticosteroid) who has been taking 20mg daily for 2 months?

Prednisone Tapering After 20mg Daily for Two Months

For a patient on prednisone 20mg daily for 2 months, taper by 5mg per week until reaching 10mg/day, then slow to 1mg every 4 weeks until discontinuation. 1

Specific Tapering Schedule

Initial Rapid Taper Phase (Weeks 1-2)

• Week 1: Reduce from 20mg to 15mg daily 1
• Week 2: Reduce from 15mg to 10mg daily 1
• This rapid initial reduction is safe because you're moving from supraphysiologic to near-physiologic doses 2

Maintenance Slow Taper Phase (Starting Week 3)

• Once at 10mg/day: Reduce by 1mg every 4 weeks until complete discontinuation 3, 1
• Alternative approach if 1mg tablets unavailable: Use alternate-day dosing (e.g., 10mg/7.5mg on alternating days, then 7.5mg/7.5mg) 3
• The slower taper below 10mg is critical because this allows time for hypothalamic-pituitary-adrenal (HPA) axis recovery 2

Administration Principles

• Give as single morning dose (before 9am) to minimize adrenal suppression, as this aligns with the body's natural cortisol peak between 2am-8am 4, 3
• Take with food or milk to reduce gastric irritation 4
• Do not use divided doses unless the patient develops prominent night pain once below 5mg daily 3

Critical Monitoring During Taper

Watch for Disease Flare

• Monitor for return of original symptoms that prompted prednisone use 1
• If disease flare occurs: Return immediately to the pre-relapse dose, maintain for 4-8 weeks until control re-established, then resume tapering more gradually 1, 5

Watch for Adrenal Insufficiency

• Key symptoms: Fatigue, weakness, dizziness, nausea, abdominal pain 6, 2
• HPA axis suppression should be anticipated since the patient received >7.5mg daily for >3 weeks 1, 6
• During acute illness or stress while tapering: Increase to hydrocortisone 50mg twice daily for 3 days 1, 6

Essential Patient Education

• Stress dosing: Educate patient to increase glucocorticoid dose during acute illness, surgery, or significant stress 1, 6
• Never stop abruptly: Emphasize the danger of sudden discontinuation after 2 months of use 4, 2
• Consider providing a medical alert card or bracelet indicating chronic steroid use 1
• Instruct patient to contact you immediately if symptoms of adrenal insufficiency develop 2

Common Pitfalls to Avoid

• Tapering too quickly below 10mg/day: This is the most common error—the slow 1mg/4-week taper is essential for HPA axis recovery 1, 2
• Stopping abruptly: Even after only 2 months at 20mg, abrupt cessation risks adrenal crisis 6, 2
• Ignoring stress dosing needs: Patients remain vulnerable to adrenal insufficiency during illness even after completing the taper, potentially for months 4, 2
• Using long-acting preparations: Stick with prednisone or prednisolone; avoid dexamethasone or betamethasone which cause prolonged HPA suppression 4

Special Considerations

If Patient Has Comorbidities

• For patients with diabetes, osteoporosis, glaucoma, or hypertension, the faster initial taper (getting off higher doses quickly) is particularly beneficial to minimize adverse effects 3

Total Expected Duration

• Approximately 3-4 months total: 2 weeks to reach 10mg, then 10-12 weeks to taper the final 10mg at 1mg/4-week intervals 1

Prophylactic Measures During Taper

• Consider calcium and vitamin D supplementation given the 2-month exposure 3
• Consider proton pump inhibitor if patient has GI risk factors 3
• No need for Pneumocystis pneumonia prophylaxis at these doses and duration 3