Prednisone 20mg Tapering Regimen
For a patient on prednisone 20mg daily, reduce by 5mg per week until reaching 10mg/day (taking 2 weeks), then slow to 1mg every 4 weeks until complete discontinuation, which takes approximately 3-4 months total. 1
Initial Rapid Taper Phase (Weeks 1-2)
- Reduce from 20mg to 15mg daily in the first week, then from 15mg to 10mg daily in the second week. 1
- This rapid initial reduction minimizes cumulative steroid exposure and adverse effects while maintaining disease control. 1
- Administer as a single morning dose before 9am to minimize adrenal suppression and mimic physiological cortisol rhythm. 1, 2
- Take with food or milk to reduce gastric irritation. 1, 2
Maintenance Slow Taper Phase (Weeks 3-14)
- Once at 10mg/day, reduce by 1mg every 4 weeks until complete discontinuation. 1, 3
- This slower taper below 10mg allows for hypothalamic-pituitary-adrenal (HPA) axis recovery, which is critical after 2 months of therapy. 1, 4
- The total duration for tapering the final 10mg is approximately 10-12 weeks at 1mg per 4-week intervals. 1
Monitoring During Taper
- Monitor for return of original symptoms that prompted prednisone use at each dose reduction. 1
- Watch for signs of adrenal insufficiency including fatigue, weakness, dizziness, nausea, or abdominal pain, particularly as doses approach physiological levels (<7.5mg). 1, 4
- Follow-up visits every 4-8 weeks during tapering are recommended to assess disease activity and adverse events. 3
Managing Disease Flare
- If disease flare occurs, return immediately to the pre-relapse dose and maintain for 4-8 weeks until control is re-established. 1, 3
- After regaining control, resume tapering more gradually than the initial attempt. 1
- Consider adding steroid-sparing agents if multiple relapses occur during tapering. 3, 5
Stress Dosing Requirements
- Educate patients to increase glucocorticoid dose during acute illness, surgery, or significant stress. 1, 3
- For minor illness, double the current prednisone dose for 3 days. 3
- HPA axis suppression should be anticipated in any patient receiving >7.5mg daily for >3 weeks, and stress dosing may be needed for up to 12 months after discontinuation. 3, 4
Patient Safety Measures
- Emphasize the danger of sudden discontinuation after 2 months of use. 1
- Consider providing a medical alert card or bracelet indicating chronic steroid use. 1, 3
- Instruct patients to contact their healthcare provider immediately if symptoms of adrenal insufficiency develop. 1
Adjunctive Prophylaxis
- Consider calcium and vitamin D supplementation for bone protection. 1
- Consider proton pump inhibitor if the patient has gastrointestinal risk factors. 1
- No Pneumocystis pneumonia prophylaxis is needed at these doses and duration. 1
Common Pitfalls to Avoid
- Tapering too quickly (using 5mg weekly reductions throughout) is the most common error and leads to disease flare or symptomatic adrenal insufficiency. 3
- The 5mg weekly reductions commonly used for short courses are inappropriate after two months of therapy. 3
- Failing to slow the taper below 10mg is a critical mistake, as this is when HPA axis recovery becomes the limiting factor rather than disease control. 1, 4