When to taper systemic corticosteroids in patients with respiratory symptoms who have shown improvement in peak expiratory flow (PEF) or forced expiratory volume (FEV1) and have a history of frequent exacerbations or high-dose steroid use?

When to Taper Systemic Corticosteroids in Asthma Exacerbations

Short courses of oral corticosteroids (up to 2 weeks) do not need to be tapered and can be stopped abruptly from full dosage. 1, 2

Duration of Treatment Before Stopping

Continue systemic corticosteroids until peak expiratory flow (PEF) reaches 70% of predicted or personal best, which typically requires 5-10 days of treatment. 3, 1, 4

• For most patients, 7 days of treatment is sufficient, though some may require up to 21 days depending on severity and response 1
• Treatment should continue until lung function values return to the patient's previous best 1
• The total course for exacerbations requiring emergency department visits or hospitalization typically lasts 3-10 days 3

Evidence Against Routine Tapering

Two high-quality randomized controlled trials demonstrate that tapering provides no benefit over abrupt cessation:

• A 1993 double-blind RCT (n=35) comparing 7-day taper versus abrupt cessation after 10 days of prednisolone 40mg daily found no difference in PEFR, symptom scores, or treatment failures (p=0.82) 5
• A 1987 RCT (n=43) comparing 1-week versus 7-week tapers showed no significant difference in reexacerbation rates (52% vs 41%) or readmission rates (21% vs 22%), but the long-taper group reported more corticosteroid side effects (41% vs 14%) 6

When Tapering May Be Considered

Tapering is only necessary for courses exceeding 2 weeks, particularly if patients are NOT concurrently taking inhaled corticosteroids. 3

• For courses slightly longer than 10 days (e.g., up to 2 weeks), there is probably no need to taper, especially if patients are using inhaled corticosteroids 3
• The FDA label notes that alternate-day therapy and gradual dose reduction may be considered for patients requiring long-term pharmacologic corticosteroid therapy to minimize HPA axis suppression 2

Specific Clinical Algorithm

Follow this approach:

1. Start treatment immediately with prednisolone 30-40mg daily (adults) or 1-2 mg/kg/day (children, max 60mg/day) 1, 4

2. Monitor PEF 15-30 minutes after starting treatment and daily thereafter 1

3. Continue full dose until PEF reaches ≥70% of predicted or personal best 3, 4

4. Stop abruptly if total duration is ≤14 days 3, 1, 2

5. Consider tapering only if:

   • Duration exceeds 2 weeks AND
   • Patient is not on inhaled corticosteroids 3

Common Pitfalls to Avoid

• Do not taper short courses - This unnecessarily prolongs steroid exposure and increases side effects without reducing relapse risk 6, 5
• Do not stop prematurely - Ensure PEF has reached 70% of predicted before discontinuation 3, 4
• Do not use arbitrarily short 3-day courses without assessing clinical response 3

High-Risk Patients Requiring Closer Monitoring

Patients with the following characteristics have high reexacerbation rates (80-86%) regardless of tapering strategy: 6

• Required mechanical ventilation during initial hospitalization
• Report >2 days of worse-than-usual dyspnea during the recovery period
• History of frequent exacerbations

These patients require more aggressive maintenance therapy and closer follow-up rather than prolonged steroid tapers. 6