How do we taper oral prednisone (corticosteroid) in a patient with osteoarthritis awaiting knee replacement surgery?

Tapering Oral Prednisone in Osteoarthritis Patients Awaiting Knee Replacement

Prednisone should be discontinued entirely in patients taking it for osteoarthritis, as it provides no benefit for this condition and significantly increases surgical infection risk, with tapering done gradually (reduce by 5 mg every 3-5 days) if the patient has been on ≥20 mg daily for more than 2 weeks to avoid adrenal insufficiency. 1

Why Prednisone Should Be Stopped for Osteoarthritis

• Prednisone has no proven efficacy for osteoarthritis pain or disease modification. The American College of Rheumatology 2012 guidelines do not recommend oral corticosteroids for osteoarthritis management, and research demonstrates that low-dose prednisone (0.1 mg/kg/day) does not reduce cartilage damage, osteophyte formation, or synovial inflammation in osteoarthritis models 2, 3

• Patients on ≥15-20 mg/day prednisone have an odds ratio of 1.68 for postoperative infectious complications following total joint arthroplasty, making this a critical modifiable risk factor 1, 2

• The CDC defines 20 mg/day prednisone for ≥2 weeks as the immunosuppression threshold, and optimal surgical candidates should be on <20 mg/day when possible 2, 1

Specific Tapering Protocol

If Patient Has Been on Prednisone >2 Weeks:

• Reduce by 5 mg every 3-5 days to avoid adrenal insufficiency 1
• For example, if on 20 mg daily: taper to 15 mg for 3-5 days, then 10 mg for 3-5 days, then 5 mg for 3-5 days, then discontinue 1
• Do not stop abruptly, as this risks adrenal crisis in patients with suppressed hypothalamic-pituitary-adrenal axis 4

If Patient Has Been on Prednisone <2 Weeks:

• Can discontinue more rapidly or immediately without significant adrenal suppression risk 4

Alternative Pain Management During Taper and Preoperatively

First-Line Options:

• Oral NSAIDs (such as celecoxib) or topical NSAIDs are conditionally recommended by the American College of Rheumatology for osteoarthritis pain 2, 1
• Acetaminophen up to 4,000 mg/day can be used, though less effective than NSAIDs for moderate-to-severe pain 2

Second-Line Options:

• Tramadol may be considered for additional analgesia while awaiting surgery 2, 1
• Duloxetine 30-60 mg daily can be added as an alternative or adjunct to initial treatments 2

Intra-Articular Injections:

• Corticosteroid injections should be avoided for 3 months preceding joint replacement surgery due to infection risk 2, 5
• If the patient is more than 3 months from surgery, intra-articular corticosteroid injections can provide temporary relief 2

Critical Perioperative Considerations

• If surgery occurs before complete taper is possible, patients on ≤16 mg/day should continue their usual daily dose perioperatively rather than receiving stress-dose steroids 2
• Patients should be counseled that prednisone increases risk of manipulation under anesthesia (OR 1.23), lysis of adhesions (OR 1.58), acute kidney injury (OR 1.47), and pneumonia (OR 4.04) when used perioperatively 6

Common Pitfalls to Avoid

• Do not continue prednisone simply because the patient has been on it chronically—osteoarthritis is not an indication for systemic corticosteroids 2, 1
• Do not taper too rapidly if the patient has been on ≥20 mg daily for >2 weeks, as this risks adrenal crisis 4
• Do not assume low-dose prednisone is safe perioperatively—even doses >15 mg/day increase infection risk significantly 2, 1
• Do not give intra-articular corticosteroid injections within 3 months of planned surgery 2, 5