Tapering 5mg Prednisone
For patients on 5mg prednisone daily, taper by 1mg every 4 weeks until discontinuation, provided disease activity remains controlled. 1
Rationale for Slow Tapering at Low Doses
At 5mg daily, you are already at a low maintenance dose where the risk of adrenal insufficiency becomes significant with abrupt discontinuation. The hypothalamic-pituitary-adrenal (HPA) axis suppression should be anticipated in any patient receiving >7.5 mg daily for >3 weeks, and recovery can take up to 12 months after stopping therapy. 2
The 1mg every 4 weeks schedule is the evidence-based standard for low-dose prednisone tapering (<10mg/day). 1
Alternative Approach for Difficult Tapers
If you encounter difficulty with 1mg decrements (e.g., symptoms emerge between 5mg and 4mg), consider using 1.25mg decrements with alternate-day schedules:
- Example: Alternate between 5mg and 3.75mg (10mg/7.5mg on alternate days if using 2.5mg tablets) 1
- This provides a gentler transition and may reduce flare risk 1
Critical Monitoring During Taper
Monitor for signs of adrenal insufficiency at each step:
- Fatigue, weakness, dizziness, nausea 1
- These symptoms indicate inadequate endogenous cortisol production 2
Monitor for disease flare:
- If symptoms recur, immediately return to the pre-relapse dose (5mg in this case) 1
- Maintain that dose for 4-8 weeks before attempting a slower taper 1
Stress Dosing Requirements
During acute illness or physiologic stress while tapering or within 12 months of discontinuation, patients require supplemental glucocorticoids:
- For minor illness: Double the current prednisone dose for 3 days 1
- For patients at 5mg daily during acute stress: Increase to hydrocortisone 50mg twice daily for 3 days 1
- Patient education on stress dosing is essential 1
- Consider a medical alert bracelet for adrenal insufficiency 1
Disease-Specific Considerations
For autoimmune hepatitis specifically:
- 5mg daily represents an appropriate maintenance dose for children (0.1-0.2 mg/kg daily or 5mg daily) 3
- For adults who repeatedly flare during tapering attempts, indefinite low-dose maintenance (2.5-7.5mg/day) is acceptable with demonstrated safety 1
- Consider switching to azathioprine 2mg/kg/day as monotherapy after eliminating prednisone to avoid long-term corticosteroid exposure 1
Common Pitfall to Avoid
The most common error is tapering too quickly at low doses. The 5mg weekly reductions commonly used for short courses are completely inappropriate for patients on chronic therapy. 1 At 5mg daily, you are in the zone where adrenal recovery is the limiting factor, not just disease control—hence the need for the slow 1mg every 4 weeks schedule.
Bone Health Maintenance
Continue osteoporosis prophylaxis throughout the taper and for at least 12 months after discontinuation: