Tapering to 15mg Prednisone in RSV Infection
For a patient with RSV infection who has been on 20mg prednisone daily for 5 days, tapering to 15mg is reasonable, but the evidence does not support continuing corticosteroids at all for RSV infection. The most appropriate action is to discontinue the prednisone entirely rather than taper to 15mg, as corticosteroids have not been shown to benefit RSV infection and may cause harm.
Evidence Against Corticosteroids in RSV Infection
The largest randomized controlled trial of 147 infants with RSV infection found that prednisolone 2 mg/kg daily for 5 days had no effect on duration of hospitalization, illness duration, or any outcome measures at 1 month or 1 year follow-up 1
Multiple studies demonstrate that corticosteroids are not effective for mild RSV infection, and evidence for benefit even in severe RSV infection remains inconclusive 2
In adult allogeneic stem cell transplant recipients with RSV, corticosteroid use was associated with higher rates of progression from upper to lower respiratory tract infection (RR 2.49), hospital admission (RR 2.05), and ICU admission (RR 2.91) 3
A study of hospitalized adults with RSV found that while short-course steroids did not significantly affect viral load or shedding, antibody responses to RSV were blunted in the steroid-treated group, suggesting potential immunologic harm 4
Safe Discontinuation After 5 Days
After only 5 days of prednisone at 20mg daily, abrupt discontinuation is safe without tapering 5
The American College of Rheumatology advises that courses under 2 weeks at this dose can be stopped abruptly without risk of adrenal insufficiency 5
Adrenal suppression should only be assumed in patients receiving more than 5 mg/day prednisone equivalent for more than 1 month 5
If Tapering is Clinically Necessary
If there is a compelling clinical reason to taper (such as underlying inflammatory condition requiring corticosteroids):
15mg daily represents a reasonable intermediate dose that falls within the range considered for maintenance therapy in various conditions 6
For chronic conditions requiring long-term steroids, doses of 15-20mg every other day may be adequate as maintenance therapy 6
The dose should be guided by the underlying condition being treated, not the RSV infection itself
Critical Caveats
Glucocorticoids may increase the risk of secondary infection and delay viral clearance in respiratory infections 5
If the patient is wheezing or has bronchospasm related to the RSV infection, this represents a different clinical scenario where short-term steroids (1-2 mg/kg/day for 3-5 days) may be appropriate for the bronchospasm itself 5
Any continuation of steroids should be for a specific indication other than RSV infection (such as underlying COPD exacerbation, asthma, or other inflammatory condition)