Prednisone Tapering from 60mg to 10mg
For most clinical situations requiring prednisone tapering from 60mg, reduce to 40mg after 1-2 weeks, then taper by 5mg every 1-2 weeks until reaching 10mg, followed by slower tapering at 1mg every 4 weeks below 10mg to minimize adrenal insufficiency risk. 1
Standard Tapering Protocol
High-Dose Phase (60mg to 10mg)
Start at 60mg daily as a single morning dose (before 9am to align with natural cortisol rhythm and minimize adrenal suppression) 2
Reduce to 40mg after 1-2 weeks, then continue tapering by 5mg decrements every 1-2 weeks until reaching 10mg 1, 3
The goal is to reach 10mg/day within 4-8 weeks from the initial high dose 1, 3
Low-Dose Phase (Below 10mg)
Once at 10mg or below, slow the taper dramatically to 1mg every 4 weeks to prevent adrenal insufficiency 1, 3
This slower taper is critical because hypothalamic-pituitary-adrenal axis suppression occurs with doses >7.5mg daily for >3 weeks 3
Alternative approach: Use 1.25mg decrements with alternate-day schedules (e.g., alternating 10mg/7.5mg on different days) 3
Critical Administration Principles
Always administer as a single daily dose in the morning before 9am unless the patient has prominent night pain on low doses (<5mg) 1, 2
Take with food or milk to reduce gastric irritation 2
Consider antacids between meals when using large doses to prevent peptic ulcers 2
Disease-Specific Modifications
For Immune-Related Adverse Events (Checkpoint Inhibitors)
If starting from grade 2-3 toxicity: Begin at 20mg daily, maintain until symptoms improve to grade 1, then taper over 3-4 weeks 4
Resume prednisone <10mg before restarting checkpoint inhibitor therapy 4
For Nephrotic Syndrome (Pediatric)
After 6 weeks at 60mg/m² daily, switch to 40mg/m² on alternate days for 6 weeks, then taper at 10mg/m² per week to 5mg on alternate days 4
Total treatment duration is typically 16 weeks 4
Monitoring During Tapering
Schedule follow-up every 4-8 weeks during the first year of tapering, then every 8-12 weeks thereafter 3
Monitor for disease activity markers and signs of adrenal insufficiency (fatigue, weakness, nausea, hypotension) 3
If disease flare occurs, immediately return to the pre-relapse dose and maintain for 4-8 weeks before attempting a slower taper 1, 3
Stress Dosing Requirements
Any patient on >7.5mg daily for >3 weeks requires stress-dose steroids during acute illness 3
For minor illness: Double the current prednisone dose for 3 days 3
For patients at 10mg daily during acute stress: Increase to hydrocortisone 50mg twice daily for 3 days 3
Continue stress dosing precautions for up to 12 months after discontinuation 3
Consider providing a medical alert bracelet for adrenal insufficiency 3
Common Pitfalls to Avoid
Tapering too quickly below 10mg is the most common error and leads to disease flare or symptomatic adrenal insufficiency 3
The 5mg weekly reductions appropriate for short courses are inappropriate after prolonged therapy 3
Failing to educate patients about stress dosing during sick days can result in adrenal crisis 3
Never abruptly discontinue prednisone after long-term therapy (>3 weeks at therapeutic doses) 2