What is the recommended tapering schedule for patients on long-term prednisolone (corticosteroid) therapy?

Prednisolone Tapering Schedule for Long-Term Therapy

For patients on long-term prednisolone therapy, taper by 5-10 mg weekly until reaching 10 mg/day, then slow dramatically to 1 mg every 4 weeks until discontinuation, with single morning dosing before 9 AM to minimize HPA axis suppression. 1, 2

Dose-Dependent Tapering Protocol

High-Dose Tapering (>30 mg/day)

• Reduce by 5-10 mg weekly until reaching 10 mg/day 1, 2
• Monitor for disease flare every 4-8 weeks during this phase 1
• Once at 10 mg/day, transition immediately to slow taper protocol 1

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

• Reduce by 5 mg every 1-2 weeks until reaching 10 mg/day 1, 2
• Then taper by 2.5 mg every 2-4 weeks once at 10 mg/day 1

Low-Dose Tapering (<10 mg/day) - Critical Slow Phase

• Reduce by only 1 mg every 4 weeks until complete discontinuation 1, 2
• This slow taper below 10 mg is essential because HPA axis recovery takes longer if suppression has been prolonged 3
• If 1 mg tablets unavailable, use alternate-day dosing schedules (e.g., 5 mg/4 mg alternating days) to achieve gradual reductions 1

Critical Timing and Administration

Administer as single morning dose before 9 AM to align with the body's natural cortisol rhythm and minimize HPA axis suppression 2, 3. The only exception is for prominent night pain while on doses <5 mg daily, where divided dosing may be considered 1, 2.

Managing Relapse During Tapering

If symptoms recur at any point, immediately return to the previous effective dose (the pre-relapse dose), maintain for 4-8 weeks until disease control is re-established, then attempt a slower taper 1, 2. This is the most common pitfall—continuing to taper despite early signs of relapse 1.

Monitoring Requirements

• Follow-up visits every 4-8 weeks during the first year of tapering 1
• Every 8-12 weeks in the second year 1
• Monitor for both disease flare AND adrenal insufficiency symptoms 2, 3
• Check disease-specific markers (e.g., aminotransferases monthly for autoimmune hepatitis, inflammatory markers for rheumatic diseases) 1

Stress Dosing Requirements - Critical Safety Measure

Patients require supplemental glucocorticoids during acute illness or physiologic stress while tapering or within 12 months of discontinuation 1, 2:

• Minor illness: Double the current prednisone dose for 3 days 1, 2
• Major stress/surgery: Hydrocortisone 50 mg 2-3 times daily 1, 2
• All patients should carry a steroid alert card or medical alert bracelet 1, 3

Special Considerations When Steroid-Sparing Agents Are Added

If azathioprine or other steroid-sparing agents have been established for 2-3 months, you can accelerate the taper more aggressively 1:

• Reduce by 5 mg every week until reaching 10 mg/day (faster than standard tapering) 1
• Then taper by 2.5 mg every 2-4 weeks once at 10 mg/day 1
• Monitor disease markers monthly during this accelerated phase 1
• Do not accelerate if the steroid-sparing agent has been started less than 2-3 months ago, as therapeutic levels may not yet be established 1

Common Pitfalls to Avoid

• Tapering too quickly is the most common error and leads to disease flare or symptomatic adrenal insufficiency 1
• The 5 mg weekly reductions commonly used for short courses are inappropriate after long-term therapy 1
• Failing to provide patient education about stress dosing for sick days 1, 3
• Not monitoring for disease activity during tapering, which may miss early signs of relapse 1

When Indefinite Low-Dose Maintenance Is Acceptable

For patients who repeatedly flare during multiple tapering attempts, indefinite low-dose maintenance (2.5-7.5 mg/day) is acceptable with demonstrated effective and acceptable safety profiles 1. Consider adding steroid-sparing agents if multiple relapses occur 1, 2.