Guidelines for Tapering Steroids in Nephrotic Syndrome
For patients who achieve remission, corticosteroids should be tapered slowly over a total period of up to 6 months after achieving remission, with the specific approach varying by disease type and patient age. 1, 2
Initial Episode - Children with Steroid-Sensitive Nephrotic Syndrome
Tapering Protocol:
- After 4-6 weeks of daily prednisone at 60 mg/m²/day (maximum 60 mg), switch to alternate-day dosing at 40 mg/m² on alternate days 1, 2
- Continue alternate-day therapy for 6 weeks, then taper by 10 mg/m² per week until reaching 5 mg on alternate days 1
- Total treatment duration should be at least 12 weeks, with tapering extending up to 16 weeks 1, 2
Key Principle: Longer initial treatment courses (up to 6 months total) reduce relapse rates compared to shorter courses, even though this means higher cumulative steroid exposure initially 1, 3
Relapse Treatment - Tapering Approach
Infrequent Relapses:
- Give 60 mg/m²/day until remission (urine dipstick trace/negative for 3 consecutive days) 1, 2
- Switch to 40 mg/m² on alternate days for 4 weeks 1
- No extended taper needed for infrequent relapsers 1
Frequent Relapses or Steroid-Dependent Disease:
- Give 60 mg/m²/day until remission (3 consecutive days) 1, 2
- Switch to 40 mg/m² on alternate days for 1 week 1
- Then taper by 10 mg/m² per week to complete a total of 4 weeks 1
- Consider low-dose maintenance therapy (0.2-0.3 mg/kg daily) for up to 12 months, which is more effective than alternate-day dosing in preventing relapses 4
Adults with Minimal Change Disease or FSGS
Tapering Protocol:
- After achieving remission with daily prednisone at 1 mg/kg/day (maximum 80 mg) for 4-16 weeks, taper slowly over 6 months 1
- Switch to alternate-day dosing at 2 mg/kg (maximum 120 mg) 1
- Gradual dose reduction over the 6-month period minimizes relapse risk 1, 5
- In adults, alternate-day prednisone for 1 year after the initial attack decreases relapse risk 6
Critical Tapering Considerations
Do Not Taper Too Quickly:
- Rapid tapering increases relapse rates significantly 3
- Patients who received shorter courses (2 months) had relapse rates of 81% versus 59% with longer courses (6 months) 1, 3
- The mean duration of remission was half as long (79 versus 169 days) with shorter treatment courses 3
Monitor During Tapering:
- Check urine dipstick daily during the taper phase 2
- Monitor blood pressure and potassium levels 2
- Watch for signs of relapse (≥2+ proteinuria for 3 consecutive days or ≥2+ proteinuria with edema) 1
When to Consider Steroid-Sparing Agents Instead of Prolonged Tapering:
- If patient develops steroid dependence (relapses during taper or within 2 weeks of stopping) 1
- If significant steroid toxicity occurs (uncontrolled diabetes, psychiatric symptoms, severe osteoporosis) 1
- Consider cyclophosphamide, cyclosporine, or levamisole as alternatives 1, 6
Special Populations
Steroid-Resistant Cases:
- Do not continue tapering steroids beyond 8-16 weeks if no response 1
- Switch to calcineurin inhibitors (cyclosporine 3-5 mg/kg/day or tacrolimus 0.05-0.1 mg/kg/day) with low-dose corticosteroids 1
Membranous Nephropathy:
- Corticosteroids should NOT be used as monotherapy 7
- When used in combination regimens (Ponticelli protocol), methylprednisolone 1 gram IV for 3 days followed by oral prednisone 0.5 mg/kg/day for the remainder of months 1,3, and 5 7
- Taper is built into the cyclical regimen rather than a continuous taper 7