From the Research
For an 88-year-old female with bullous pemphigoid who has been on 15mg prednisone daily for 4 months, I recommend a slow, gradual taper to minimize the risk of disease flare and adrenal insufficiency, starting with a reduction to 12.5mg daily for 2 weeks, then 10mg daily for 2 weeks, followed by 7.5mg daily for 2 weeks, 5mg daily for 2 weeks, 2.5mg daily for 2 weeks, and finally 2.5mg every other day for 2 weeks before discontinuation, as supported by the most recent evidence 1. This slow taper is particularly important given the patient's advanced age and prolonged steroid use, which increases her risk of adrenal suppression. During the taper, closely monitor for signs of disease recurrence (new blisters, pruritus, or erythema) and symptoms of adrenal insufficiency (fatigue, weakness, dizziness, nausea). Some key points to consider during the taper include:
- The use of topical corticosteroids, which have been shown to be effective in treating bullous pemphigoid with fewer adverse effects compared to systemic steroids 2, 3
- The potential addition of steroid-sparing agents, such as azathioprine, which may help reduce the required dose of prednisone 2, 3
- The importance of calcium and vitamin D supplementation to protect bone health, particularly in patients with bullous pemphigoid who are at increased risk of osteoporosis and fractures 4
- Regular monitoring of blood pressure and blood glucose, especially in the early phases of the taper, to minimize the risk of adverse effects associated with steroid use 5. If bullous pemphigoid flares during the taper, return to the previous effective dose and consider adding a steroid-sparing agent such as doxycycline, nicotinamide, or immunosuppressants like azathioprine or mycophenolate mofetil.