How to safely taper off prednisone (corticosteroid)?

How to Taper Prednisone

For most patients on prednisone therapy longer than 3 weeks, taper by reducing to 10 mg/day within 4-8 weeks, then decrease by 1 mg every 4 weeks until discontinuation, with the tapering speed individualized based on initial dose, duration of therapy, and underlying condition. 1

General Principles

• Single daily morning dosing (before 9 AM) is strongly preferred to minimize HPA axis suppression, as this aligns with the body's natural cortisol peak between 2-8 AM 2
• Tapering is necessary for any course exceeding 3 weeks to prevent adrenal insufficiency, which can persist up to 12 months after discontinuation 1, 2
• HPA axis suppression should be anticipated in any patient receiving >7.5 mg daily for >3 weeks 1
• Never abruptly discontinue prednisone - gradual withdrawal is essential to allow adrenal recovery 2

Tapering Schedule Based on Initial Dose

High-Dose Therapy (>30 mg/day)

Initial Rapid Taper (Weeks 1-8):

• Reduce to 10 mg/day within 4-8 weeks using the following approach: 3, 1
  • Week 1: 30 mg daily
  • Week 2: 20 mg daily
  • Week 3: 15 mg daily
  • Weeks 4-8: Gradually reduce to 10 mg daily

Maintenance Taper (After Week 8):

• Once at 10 mg/day, slow the taper dramatically to 1 mg every 4 weeks until discontinuation 3, 1
• Alternative approach: Use 2.5 mg reductions every 10 weeks if 1 mg tablets unavailable 3, 1

Medium-Dose Therapy (10-30 mg/day)

• Taper by 5 mg every week until reaching 10 mg/day 1
• Then slow to 2.5 mg/week until reaching 5 mg/day 1
• Below 5 mg/day, reduce by 1 mg every 4 weeks 1

Low-Dose Therapy (<10 mg/day)

• Taper by 1 mg every 4 weeks - this is the critical slow phase where adrenal recovery occurs 3, 1
• If 1 mg tablets unavailable, use alternate-day dosing schedules (e.g., 10/7.5 mg on alternating days) 1

Special Situations

Split Dosing Exception

• Only consider split doses for prominent night pain while tapering below 5 mg daily - otherwise maintain single morning dosing 3, 1
• Persistent breakthrough symptoms should prompt reconsideration of the diagnosis 3

Short-Course Therapy (<3 weeks)

• For acute conditions like asthma exacerbations treated for 7-10 days, tapering is unnecessary - abrupt discontinuation at 40 mg/day for 10 days does not cause rebound or relapse 4, 5, 6
• This applies only to patients not previously on chronic steroids 4, 6

Disease-Specific Modifications

Polymyalgia Rheumatica

• Initial dose: 12.5-25 mg daily 3, 1
• Reduce to 10 mg/day within 4-8 weeks 3
• Then 1 mg every 4 weeks until discontinuation 3

Autoimmune Conditions with Steroid-Sparing Agents

• When azathioprine or mycophenolate is established (after 2-3 months), accelerate the taper: 1
  • Reduce by 5 mg every week until 10 mg/day
  • Then 2.5 mg every 2-4 weeks below 10 mg/day
• Monitor disease markers monthly during accelerated tapering 1

Immune-Related Adverse Events (from immunotherapy)

• Start at 1-2 mg/kg/day depending on severity 3, 1
• Taper over 4-6 weeks once symptoms improve to grade 1 3, 1

Critical Monitoring During Tapering

Clinical Assessment Schedule

• Every 4-8 weeks during the first year of tapering 3, 1
• Every 8-12 weeks in the second year 3
• More frequently if disease activity increases 1

Signs of Adrenal Insufficiency to Monitor

• Fatigue, weakness, nausea, hypotension, hypoglycemia 2
• Patients require stress-dose steroids during acute illness for up to 12 months after discontinuation 2

Stress Dosing Requirements

• During acute illness or physiologic stress while tapering or within 12 months of stopping: 1, 2
  • Minor illness: Double current prednisone dose for 3 days
  • Moderate stress: Hydrocortisone 50 mg twice daily for 3 days
  • Severe stress: Hydrocortisone 50 mg three times daily
• Consider medical alert bracelet for patients on chronic therapy 1

Managing Relapse During Tapering

If disease flare occurs:

• Immediately return to the pre-relapse dose and maintain for 4-8 weeks until disease control is re-established 3, 1
• Resume tapering at half the previous rate 1, 7
• Consider adding steroid-sparing agents if multiple relapses occur 1

Common pitfall: Failing to increase the dose quickly enough when relapse occurs - delays in treatment can lead to more severe flares requiring higher doses 1

Supportive Measures During Tapering

Prophylaxis Requirements

• PCP prophylaxis: Required if ≥20 mg for ≥4 weeks 8, 7
• PPI therapy: For all patients on moderate-to-high doses 8, 7
• Calcium (1000 mg/day) and vitamin D (400-800 units/day): Start at initiation of therapy 8, 9

Monitoring for Steroid-Related Adverse Effects

• Blood pressure, glucose, weight, bone density 1
• Ophthalmologic examination for cataracts/glaucoma if prolonged use 2

Common Pitfalls to Avoid

• Tapering too quickly - the most common error leading to disease flare or symptomatic adrenal insufficiency 1
• Using 5 mg weekly reductions after prolonged therapy (>2 months) - this is only appropriate for short courses 1
• Failing to provide stress-dosing education before discontinuation 1
• Not monitoring for disease activity during tapering, missing early relapse signs 1
• Accelerating taper before steroid-sparing agents reach therapeutic levels (requires 2-3 months for azathioprine) 1

Long-Term Maintenance Considerations

• Many patients with chronic autoimmune conditions require indefinite low-dose maintenance (2.5-7.5 mg/day) rather than complete discontinuation 1
• This is acceptable with appropriate monitoring and prophylaxis, particularly for patients who repeatedly flare during tapering attempts 1
• Consider switching to steroid-sparing agents (azathioprine, mycophenolate) as monotherapy after eliminating prednisone 1