Steroid Tapering Protocol for Infantile Spasms
After achieving spasm cessation with high-dose prednisolone (8 mg/kg/day, maximum 60 mg/day) for 2 weeks, taper the dose over 2 weeks by reducing it gradually, then discontinue. 1, 2
Initial Treatment Duration
- Administer prednisolone at 8 mg/kg/day (maximum 60 mg/day) divided into three daily doses for 14 days 1, 2
- Confirm response with video-EEG showing resolution of both epileptic spasms and hypsarrhythmia on day 14 1, 2
Tapering Schedule for Responders
The taper should occur over 14 days following the initial 2-week treatment course. 1, 2
- Begin tapering only after confirming complete response (absence of spasms and hypsarrhythmia on video-EEG) 1, 2
- The specific taper schedule involves gradual dose reduction over 2 weeks, though the exact daily decrements are not rigidly specified in the protocols 1, 2
- One case report used a 5-week taper after 2 weeks of full-dose therapy 3
Management of Non-Responders
If no response after 14 days of prednisolone, immediately transition to ACTH without tapering. 1, 2
- Switch to natural ACTH at 150 U/m²/day divided in two daily doses for 14 days 1
- This sequential approach yields cumulative response rates of 84% in treatment-naive patients 1
- Among prednisolone non-responders, 33-40% will respond to subsequent ACTH therapy 1, 2
Critical Monitoring Points
Relapse risk is substantial even after initial response, occurring in 12-50% of cases between 2-9 months. 1, 2
- Monitor closely for relapse during the 28 days following taper completion 1
- Prednisolone responders have lower relapse rates (12%) compared to ACTH responders (50%) 2
- Extended follow-up is essential as late relapses can occur up to 9 months post-treatment 2
Important Caveats
Treatment-naive patients have significantly better outcomes (84% response) compared to those with prior hormonal therapy exposure (51% response). 1
- The 8 mg/kg/day dose is substantially higher than traditional prednisolone dosing and demonstrates superior efficacy compared to lower doses used in earlier studies 2
- Adverse effects are less frequent with prednisolone (53%) compared to ACTH (80%) 4
- Cost considerations strongly favor prednisolone ($200) over ACTH (approximately $70,000) 4
Do not use abrupt discontinuation after long-term therapy; gradual withdrawal is essential to prevent adrenal insufficiency. 5