What are the instructions for tapering prednisone (corticosteroid) in a patient?

Prednisone Tapering Instructions

The tapering schedule for prednisone depends critically on the initial dose and duration of therapy: for high doses (>30 mg/day), taper to 10 mg/day over 4-8 weeks then reduce by 1 mg every 4 weeks; for medium doses (10-30 mg/day), reduce by 5 mg weekly to 10 mg/day then by 2.5 mg weekly to 5 mg/day; for low doses (<10 mg/day), taper by 1 mg every 4 weeks until discontinuation. 1

General Principles

• Single daily morning dosing (before 9 am) is strongly preferred to minimize adrenal suppression, as the adrenal cortex has maximal activity between 2 am and 8 am 2, 1
• Any patient receiving >7.5 mg daily for >3 weeks requires tapering to prevent adrenal insufficiency 1, 3
• The FDA label emphasizes that dosage requirements are variable and must be individualized, with gradual withdrawal rather than abrupt discontinuation after long-term therapy 2

Specific Tapering Schedules by Initial Dose

High Initial Doses (>30 mg/day)

• Reduce to 10 mg/day within 4-8 weeks, then slow the taper to 1 mg every 4 weeks until discontinuation 1
• For inflammatory arthritis: Start at 20 mg daily for 2-4 weeks, then taper over 4-8 weeks 1
• For immune-related adverse events (grade 3-4): Start at 1-2 mg/kg/day, taper over 4-6 weeks once symptoms improve to grade 1 4, 1

Medium Initial Doses (10-30 mg/day)

• Taper by 5 mg every week until reaching 10 mg/day 1
• Then slow to 2.5 mg/week until reaching 5 mg/day 1
• For immune-related adverse events (grade 2): Start at 1 mg/kg/day, taper over 4-6 weeks if improvement occurs 4

Low Doses (<10 mg/day)

• Taper by 1 mg every 4 weeks until complete discontinuation 1, 3
• Alternative approach: Use 1.25 mg decrements with alternate-day schedules (e.g., 10/7.5 mg alternate days) if 1 mg tablets unavailable 1

Short Courses (2 weeks or less)

• For acute conditions: 40 mg daily for 3-4 days, then reduce by 5 mg every 2-3 days until completion 5
• Important caveat: For short courses (<3 weeks), tapering may not be necessary based on research showing no difference in relapse rates between tapered and non-tapered courses in acute asthma 6, 7

Managing Relapse During Tapering

• If disease flare occurs, immediately return to the pre-relapse dose and maintain for 4-8 weeks before attempting a slower taper 1, 3
• Consider adding steroid-sparing agents if multiple relapses occur during tapering attempts 1
• For autoimmune hepatitis patients who repeatedly flare, indefinite low-dose maintenance (2.5-7.5 mg/day) is acceptable 1

Critical Monitoring Requirements

• Follow-up visits every 4-8 weeks during the first year of tapering, then every 8-12 weeks thereafter 1, 3
• Monitor for three key complications: disease activity markers, signs of adrenal insufficiency (fatigue, weakness, dizziness, nausea), and steroid withdrawal symptoms 3
• For autoimmune conditions: Check disease-specific laboratory markers monthly during tapering 1

Stress Dosing During and After Tapering

• During acute illness or physiologic stress while tapering, double the current prednisone dose for 3 days for minor illness 1
• For patients on 10 mg daily: Increase to hydrocortisone 50 mg twice daily for 3 days during acute stress 1
• For patients on high-dose therapy: Use hydrocortisone 50 mg three times daily during acute illness 1
• Stress dosing may be required up to 12 months after discontinuation in patients who were on prolonged therapy 1

Special Considerations When Azathioprine is Added

• Wait 2-3 months after starting azathioprine (at 2 mg/kg/day) before accelerating the prednisone taper, as azathioprine takes 6-12 weeks to reach full therapeutic effect 1
• Once azathioprine is established: Reduce prednisone by 5 mg every week until reaching 10 mg/day, then taper by 2.5 mg every 2-4 weeks 1
• Monitor aminotransferases monthly during this accelerated tapering phase 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 two months of therapy 1
• Failing to educate patients about stress dosing for sick days can result in adrenal crisis 1
• Not monitoring for disease activity during tapering may miss early signs of relapse 1
• Consider a medical alert bracelet for patients at risk of adrenal insufficiency 1