What is the equivalent dose of prednisone and recommended tapering regimen for a patient taking dexamethasone 4mg once a day?

Dexamethasone 4mg Daily: Prednisone Equivalent and Tapering Strategy

Your dexamethasone 4mg once daily is equivalent to prednisone 20mg daily, and you should taper by reducing to 10mg prednisone-equivalent within 4-8 weeks, then decrease by 1mg every 4 weeks until discontinuation. 1, 2

Dose Conversion

Dexamethasone is 5 times more potent than prednisone, meaning your current dose converts as follows: 2

• Dexamethasone 4mg = Prednisone 20mg 2

This is a moderate dose that requires careful tapering to prevent both disease flare and adrenal insufficiency. 1

Recommended Tapering Protocol

Phase 1: Initial Taper (Weeks 1-8)

Convert to prednisone 20mg daily and reduce to 10mg daily over 4-8 weeks. 1 This can be accomplished by:

• Week 1-2: Prednisone 20mg daily 1
• Week 3-4: Prednisone 15mg daily 1
• Week 5-6: Prednisone 12.5mg daily 1
• Week 7-8: Prednisone 10mg daily 1

Alternatively, you may continue dexamethasone and reduce by 0.5mg increments every 2 weeks (4mg → 3.5mg → 3mg → 2.5mg → 2mg, which equals 10mg prednisone). 2

Phase 2: Slow Maintenance Taper (After Week 8)

Once at 10mg prednisone-equivalent, reduce by 1mg every 4 weeks until discontinuation. 1 This slower taper is critical to allow hypothalamic-pituitary-adrenal axis recovery. 1

Week	Prednisone Dose	Dexamethasone Equivalent
9-12	10mg	2mg
13-16	9mg	1.8mg
17-20	8mg	1.6mg
21-24	7mg	1.4mg
25-28	6mg	1.2mg
29-32	5mg	1mg
33-36	4mg	0.8mg
37-40	3mg	0.6mg
41-44	2mg	0.4mg
45-48	1mg	0.2mg
49+	Discontinue	Discontinue

1

Critical Timing Considerations

Administer your dose in the morning before 9am to minimize adrenal suppression, as this aligns with the body's natural cortisol peak between 2am-8am. 3, 4 Single daily dosing is preferred over divided doses. 1, 2

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 This is the most common pitfall—tapering too quickly leads to disease flare or symptomatic adrenal insufficiency. 1

Monitor for signs of disease activity specific to your underlying condition during each taper step. 1 If multiple relapses occur, consider adding steroid-sparing agents rather than continuing high-dose corticosteroids long-term. 1

Adrenal Insufficiency Prevention

You are at risk for adrenal insufficiency during tapering and for up to 12 months after discontinuation. 1 Watch for:

• Fatigue, weakness, dizziness 1
• Nausea, vomiting 1
• Hypotension 1

During acute illness or physiologic stress while tapering, double your current dose for 3 days. 1 For major illness or surgery, you may need hydrocortisone 50mg twice or three times daily. 1 Consider obtaining a medical alert bracelet. 1

Special Considerations for Faster Tapering

If you are on azathioprine or another steroid-sparing agent that has been established for 2-3 months, you may taper more aggressively: 1

• Reduce by 5mg prednisone-equivalent every week until reaching 10mg daily 1
• Then taper by 2.5mg every 2-4 weeks once at 10mg daily 1
• Monitor disease markers monthly during this accelerated phase 1

This approach reduces corticosteroid-related side effects from 44% to 10% when combined with adequate immunosuppression. 1

Common Pitfalls to Avoid

• Never taper faster than 1mg every 4 weeks once below 10mg prednisone-equivalent 1
• Do not stop abruptly after more than 3 weeks of therapy 1, 3
• Ensure adequate steroid-sparing medication is established before accelerating taper 1
• Monitor for both disease activity and adrenal insufficiency symptoms 1