What is the recommended tapering schedule for prednisone based on the patient's current dose?

Prednisone Tapering Based on Dose

The tapering schedule for prednisone depends critically on the starting dose and duration of therapy: for high doses (>30 mg/day), taper to 10 mg/day over 4-8 weeks then reduce by 1 mg every 4 weeks; for medium doses (10-30 mg/day), reduce by 5 mg weekly to 10 mg/day then by 2.5 mg weekly to 5 mg/day; and for low doses (<10 mg/day), taper by 1 mg every 4 weeks until discontinuation. 1

High-Dose Tapering (>30 mg/day)

For patients starting at doses above 30 mg/day:

• Reduce the dose to 10 mg/day within 4-8 weeks 1
• Once at 10 mg/day, slow the taper to 1 mg decrements every 4 weeks until discontinuation 1
• For immune-related adverse events requiring 1-2 mg/kg/day (typically 60-80 mg/day), taper over 4-6 weeks once symptoms improve to grade 1 2, 1
• Single daily morning dosing is preferred to minimize adrenal suppression 1, 3

Disease-specific high-dose examples:

• Inflammatory myopathies (60-80 mg/day): Taper by 10 mg every 2 weeks until reaching 30 mg/day, then by 5 mg every 2 weeks to 20 mg/day, then by 2.5 mg every 2 weeks; at 10 mg/day, slow to 1 mg every 2-4 weeks 1
• Immune checkpoint inhibitor toxicity (grade 3-4): Start methylprednisone 2-4 mg/kg IV, then taper over 4-6 weeks once improved 2

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

For patients on 10-30 mg/day:

• Taper by 5 mg every week until reaching 10 mg/day 1
• Then slow the taper to 2.5 mg per week until reaching 5 mg/day 1
• Once below 5 mg/day, switch to 1 mg decrements every 4 weeks 1

Example for 20 mg/day starting dose:

• Weeks 1-2: 15 mg/day 1
• Weeks 3-4: 10 mg/day 1
• Weeks 5-6: 7.5 mg/day 1
• Weeks 7-8: 5 mg/day 1
• Then continue with 1 mg every 4 weeks 1

Low-Dose Tapering (<10 mg/day)

For patients on maintenance doses below 10 mg/day:

• Taper by 1 mg every 4 weeks until discontinuation 1
• Alternative approach: Use 1.25 mg decrements with alternate-day schedules (e.g., alternating 10 mg and 7.5 mg) 1
• This slow taper is critical to prevent both disease flare and adrenal insufficiency 1

Specific schedule for 5 mg/day:

Weeks	Daily Dose
1-4	5 mg [1]
5-8	4 mg [1]
9-12	3 mg [1]
13-16	2 mg [1]
17-20	1 mg [1]
21+	Discontinue [1]

Short-Course Tapering (≤3 Weeks)

For courses of 14-20 days:

• 14-day course: Full dose (1 mg/kg/day, max 60 mg) for 7 days, then reduce by 10 mg every 2 days 4
• 20-day course: Start 40 mg daily for 3 days, then reduce by 5 mg every 2-3 days 5
• For courses under 3 weeks, adrenal insufficiency risk is minimal, though tapering remains standard to prevent disease flare 5, 4

Research evidence for short courses:

• Studies in acute asthma show no difference in relapse rates between 8-day tapering versus non-tapering regimens (40 mg/day throughout), with no adrenal suppression in either group 6, 7, 8
• However, structured tapers remain the standard recommendation to minimize withdrawal symptoms 5

Special Considerations When Adding Steroid-Sparing Agents

When azathioprine or other immunosuppressants are established (after 2-3 months):

• More aggressive tapering is safe: reduce by 5 mg every week until reaching 10 mg/day 1
• Then taper by 2.5 mg every 2-4 weeks once at 10 mg/day 1
• Monitor liver enzymes monthly during accelerated taper 1
• Do not accelerate taper if the steroid-sparing agent has been started less than 2-3 months ago 1

Managing Relapse During Tapering

If disease flare occurs:

• Immediately return to the pre-relapse dose 1
• Maintain that dose for 4-8 weeks until disease control is re-established 1
• Then attempt a slower taper (half the previous reduction rate) 1
• Consider adding steroid-sparing agents if multiple relapses occur 1

Critical Monitoring and Pitfalls

Key monitoring parameters:

• Disease activity markers every 4-8 weeks during the first year of tapering 1
• Signs of adrenal insufficiency: fatigue, weakness, nausea, hypotension 1
• For patients with diabetes, increase blood glucose monitoring frequency 5

Common errors to avoid:

• Tapering too quickly is the most frequent mistake and leads to disease flare or symptomatic adrenal insufficiency 1, 5
• Failing to provide clear written instructions about the exact daily dose for each phase 5
• Not educating patients about stress dosing: double the current dose for 3 days during minor illness 1, 5
• Using inadequate initial doses (standard methylprednisolone dose packs provide only 105 mg prednisone equivalent, which is insufficient) 5, 4

Adrenal Insufficiency Prevention

For patients on therapy >3 weeks at >7.5 mg/day:

• Anticipate hypothalamic-pituitary-adrenal axis suppression 1
• During acute illness while tapering or within 12 months of discontinuation, provide supplemental glucocorticoids 1
• For minor illness: double current prednisone dose for 3 days 1, 5
• For major stress: hydrocortisone 50 mg twice daily (if on 10 mg/day prednisone) or three times daily (if on high-dose therapy) 1
• Consider medical alert bracelet for patients on chronic therapy 1

Disease-Specific Protocols

Polymyalgia rheumatica:

• Initial dose: 12.5-25 mg daily 1
• Taper to 10 mg/day within 4-8 weeks 1
• Then reduce by 1 mg every 4 weeks until discontinuation 1

Autoimmune hepatitis:

• Adults: Start 30 mg/day with azathioprine, taper to 10 mg/day for maintenance 1
• Children: Start 1-2 mg/kg/day (max 60 mg), taper over 6-8 weeks to 0.1-0.2 mg/kg daily or 5 mg daily 1

Giant cell arteritis:

• Initial dose: 40-60 mg/day 1
• Taper to 15-20 mg/day within 2-3 months 1
• Reduce to ≤5 mg/day after 1 year 1