What is the recommended approach for tapering a dose of prednisone (corticosteroid) in a patient?

Prednisone Tapering Protocol

The optimal prednisone taper depends on your starting dose: for high doses (>30 mg/day), reduce to 10 mg/day within 4-8 weeks, then slow to 1 mg every 4 weeks until discontinuation; for medium doses (10-30 mg/day), reduce by 5 mg weekly to 10 mg/day then switch to the slow taper; for low doses (<10 mg/day), reduce by 1 mg every 4 weeks. 1, 2, 3

Critical Timing Principles

• Always administer prednisone as a single morning dose before 9 AM to align with your body's natural cortisol rhythm and minimize adrenal suppression 2, 4
• Any patient receiving more than 7.5 mg daily for more than 3 weeks requires tapering to prevent adrenal insufficiency 1, 3
• Divided dosing should only be considered for prominent night pain while on doses below 5 mg daily 1, 2

Dose-Specific Tapering Schedules

High Initial Doses (>30 mg/day)

• Reduce by 5-10 mg weekly until reaching 10 mg/day 1, 2
• Once at 10 mg/day, transition to the slow taper protocol below 1, 3

Medium Initial Doses (10-30 mg/day)

• Reduce by 5 mg every 1-2 weeks until reaching 10 mg/day 1, 2
• Then slow to 2.5 mg every 2-4 weeks until reaching 5 mg/day 1
• Once below 5 mg/day, reduce by 1 mg every 4 weeks 1, 2

Low Doses (<10 mg/day)

• Reduce by 1 mg every 4 weeks until complete discontinuation 1, 2, 3
• If 1 mg tablets are unavailable, use alternate-day dosing schedules (e.g., 5 mg/4 mg alternating days) to achieve gradual reductions 1

Disease-Specific Modifications

For Immune-Related Adverse Events (Checkpoint Inhibitors)

• Grade 2 events: Start 0.5-1 mg/kg/day (approximately 40-80 mg/day), taper over 4-6 weeks once symptoms improve to grade ≤1 5, 1, 3
• Grade 3-4 events: Start 1-2 mg/kg/day, taper over 4-6 weeks once symptoms improve to grade ≤1 5, 1, 3

For Polymyalgia Rheumatica

• Initial dose: 12.5-25 mg daily 1, 2
• Taper to 10 mg/day within 4-8 weeks 1, 2
• Then reduce by 1 mg every 4 weeks until discontinuation 1, 2

For Inflammatory Myopathies

• Initial dose: 0.5-1 mg/kg/day (typically 60-80 mg/day) 1
• Taper by 10 mg every 2 weeks until reaching 30 mg/day 1
• Then taper by 5 mg every 2 weeks until reaching 20 mg/day 1
• Then taper by 2.5 mg every 2 weeks until reaching 10 mg/day 1
• At 10 mg/day, slow to 1 mg every 2-4 weeks until completed 1

Managing Disease Flare During Tapering

• If symptoms recur at any point, immediately return to the pre-relapse dose and maintain for 4-8 weeks before attempting a slower taper 1, 2, 3
• Consider adding steroid-sparing agents (azathioprine, methotrexate, mycophenolate) if multiple relapses occur during tapering attempts 1, 3
• For patients on azathioprine, wait 2-3 months before accelerating the prednisone taper, as azathioprine takes 6-12 weeks to reach full therapeutic effect 1, 3

Stress Dosing Requirements

• During acute illness or physiologic stress while tapering, double your current prednisone dose for 3 days for minor illness 1, 2, 3
• For major stress or surgery, use hydrocortisone 50 mg 2-3 times daily 1, 2
• Stress dosing may be required up to 12 months after discontinuation in patients on prolonged therapy 1, 3
• Consider providing patients with a medical alert bracelet for adrenal insufficiency 1

Monitoring Schedule

• Follow-up visits every 4-8 weeks during the first year of tapering 1, 3
• Then every 8-12 weeks in the second year 1, 3
• Monitor for three key complications: disease activity markers, signs of adrenal insufficiency (fatigue, weakness, nausea, hypotension), and steroid withdrawal symptoms 1, 3

Critical 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
• Never stop prednisone abruptly after prolonged use—always taper gradually 4
• Failing to provide stress dosing instructions for sick days can result in adrenal crisis 1

Special Exception: Short-Course Asthma Treatment

• For acute asthma exacerbations treated in the emergency department with short courses (7-10 days), tapering may not be necessary 6, 7, 8
• Studies show no difference in relapse rates between abrupt discontinuation and tapering after 7-10 day courses of 40 mg daily 7, 8
• However, this exception only applies to short-term use in patients not previously on chronic steroids 6, 7