Prednisone Withdrawal After 20 mg Daily for Several Weeks
You should taper prednisone gradually over 4-8 weeks rather than stopping abruptly, as your hypothalamic-pituitary-adrenal (HPA) axis is suppressed after several weeks at 20 mg daily, and abrupt discontinuation risks adrenal crisis. 1, 2
Why Tapering Is Necessary
- HPA axis suppression occurs in any patient receiving >7.5 mg daily for >3 weeks, making you at significant risk for adrenal insufficiency if you stop suddenly 1, 3
- The FDA label explicitly warns: "If after long-term therapy the drug is to be stopped, it is recommended that it be withdrawn gradually rather than abruptly" 2
- Abrupt discontinuation can cause life-threatening adrenal crisis, disease flare, and steroid withdrawal syndrome (fatigue, weakness, body aches, joint pain) 3, 4, 5
Recommended Tapering Schedule
Initial Phase (Weeks 1-4):
- Reduce from 20 mg to 10 mg daily over 4-8 weeks 1, 6
- Practical approach: Decrease by 2.5-5 mg every 1-2 weeks 1, 6
- Example: 20 mg → 15 mg (week 2) → 12.5 mg (week 4) → 10 mg (week 6) 1
Maintenance Phase (Once at 10 mg):
- Slow the taper to 1 mg every 4 weeks until discontinuation 7, 1, 6
- This slower reduction allows your adrenal glands to gradually resume cortisol production 4, 5
Alternative schedule if you need faster tapering:
- Reduce by 5 mg every week until reaching 10 mg/day 1
- Then reduce by 2.5 mg every 2 weeks until reaching 5 mg/day 6
- Finally reduce by 1 mg every 4 weeks until discontinuation 1, 6
Critical Monitoring During Tapering
Watch for signs of adrenal insufficiency:
- Severe fatigue, weakness, dizziness (especially upon standing) 5
- Nausea, vomiting, abdominal pain 5
- Low blood pressure, confusion 5
If disease symptoms return during tapering:
- Immediately return to the pre-relapse dose and maintain for 4-8 weeks 7, 1, 6
- Then attempt a slower taper 1, 6
Stress Dosing Requirements
- During acute illness or stress while tapering, double your current prednisone dose for 3 days 1, 6
- For major stress (surgery, severe infection), you may need hydrocortisone 50-100 mg three times daily 7
- Consider carrying a medical alert card/bracelet indicating adrenal insufficiency risk 7, 6
Common Pitfalls to Avoid
Tapering too quickly is the most common error and leads to:
- Disease flare requiring restarting higher doses 1, 3
- Symptomatic adrenal insufficiency 4, 5
- Steroid withdrawal syndrome (fatigue, myalgias, arthralgias) even with adequate adrenal function 4, 5
Failing to recognize adrenal insufficiency:
- Symptoms of adrenal insufficiency overlap with steroid withdrawal syndrome and the underlying disease 4, 5
- If symptoms prevent tapering, consider checking morning cortisol or ACTH stimulation test 4, 5
Special Considerations
- Take prednisone in the morning (before 9 AM) to minimize HPA axis suppression 2
- Single daily dosing is preferred over divided doses 7
- Recovery of full adrenal function may take 6-12 months after complete discontinuation 4, 5
- Research shows HPA function normalizes within 1 week after short courses (<7 days), but your "several weeks" at 20 mg requires full tapering 8, 9