What is the recommended tapering regimen for prednisone (corticosteroid) in a patient with an upper respiratory tract infection (URTI)?

Prednisone Tapering for Upper Respiratory Tract Infections

Prednisone tapering is generally not indicated for uncomplicated upper respiratory tract infections (URTIs) in otherwise healthy patients, as corticosteroids are not a standard treatment for simple URTIs. However, the clinical context matters significantly—if you're asking about prednisone use during a URTI in a patient with an underlying condition, the approach differs entirely.

For Patients WITHOUT Underlying Chronic Disease

Do not prescribe prednisone for uncomplicated URTIs. There is no evidence supporting corticosteroid use for simple upper respiratory infections in healthy individuals, and doing so exposes patients to unnecessary adverse effects including hyperglycemia, immunosuppression, and HPA axis suppression 1.

For Patients WITH COPD Experiencing an Exacerbation

If the URTI has triggered a COPD exacerbation (increased dyspnea, sputum production, or sputum purulence), the approach is clear:

Dosing Regimen

• Prescribe prednisone 30-40 mg orally daily for 5 days, then stop abruptly without tapering 2, 3.
• This short-course regimen (≤14 days) is as effective as longer courses while minimizing adverse effects 2.
• Tapering is unnecessary after short courses (≤14 days) and adds no clinical benefit 4.

Post-Treatment Management

• After completing the 5-day prednisone course, initiate or optimize inhaled corticosteroid/long-acting beta-agonist combination therapy (such as fluticasone/salmeterol) to prevent future exacerbations 5, 2.
• Monitor blood glucose at least twice daily in diabetic patients during corticosteroid therapy, as hyperglycemia occurs with an odds ratio of 2.79 2.

For Patients WITH Nephrotic Syndrome

The 2025 KDIGO guidelines provide definitive guidance based on the PREDNOS2 trial:

Evidence-Based Recommendation

• Do NOT routinely give daily glucocorticoids during URTIs to prevent relapse in children with frequently relapsing or steroid-dependent nephrotic syndrome 3, 6.
• The PREDNOS2 randomized controlled trial (n=271) demonstrated no difference in relapse rates between prednisolone (42.7%) and placebo (44.3%) when given for 6 days during URTIs (adjusted risk difference -0.02,95% CI -0.14 to 0.10, p=0.70) 6, 7.

Exception to Consider

• In highly selected children already on low-dose alternate-day prednisolone with a documented history of repeated infection-associated relapses AND significant prednisone-related morbidity, 3 extra doses of low-dose (0.5 mg/kg/day) daily prednisone can be considered at URTI onset 3.
• This is a practice point, not a strong recommendation, and should be reserved for exceptional cases 3.

For Patients WITH Asthma

• If prednisone is prescribed for an asthma exacerbation (typically 40 mg daily for 5-10 days), tapering is unnecessary 4.
• A randomized double-blind trial (n=35) showed no difference in peak expiratory flow rate, symptom scores, or treatment failures between abrupt cessation versus tapering after 10 days of prednisolone 40 mg daily (p=0.82) 4.

Critical Warnings About HPA Axis Suppression

If a patient has been on prednisone >7.5 mg daily for >3 weeks, HPA axis suppression should be anticipated and tapering becomes necessary 8, 1:

• Taper gradually to minimize adrenal insufficiency risk 1.
• The risk of adrenal insufficiency may persist 6-12 months after complete steroid withdrawal 8.
• Check 8 am cortisol levels after tapering—values >10 mcg/dL (ideally >15-20 mcg/dL) indicate adequate HPA axis recovery 8.
• Educate patients on stress-dosing protocols (increase to 10-20 mg hydrocortisone equivalent during fever, infection, surgery, or trauma) 8.

Common Pitfalls to Avoid

• Do not use a methylprednisolone dose pack (Medrol Dosepak) for COPD exacerbations—the 6-day tapering regimen provides insufficient total corticosteroid dose compared to the evidence-based 5-day prednisone course 2.
• Do not taper short courses (<14 days) of prednisone—this adds no benefit and may prolong exposure to adverse effects 4, 2.
• Do not prescribe prednisone prophylactically for URTIs in nephrotic syndrome patients based on outdated evidence—the 2025 KDIGO guidelines explicitly recommend against this practice based on high-quality RCT data 3, 6.