What is the recommended oral prednisone tapering regimen for an adult with nephrotic syndrome after an initial high‑dose induction?

Steroid Tapering Protocol for Adult Nephrotic Syndrome

For adults with nephrotic syndrome who achieve remission, taper corticosteroids slowly over a total period of up to 6 months after achieving remission. 1

Initial High-Dose Phase

• Start with prednisone 1 mg/kg/day (maximum 80 mg) as a single daily dose for initial treatment of minimal change disease (MCD) in adults 1
• Maintain this high dose for a minimum of 4 weeks if complete remission is achieved, and for a maximum of 16 weeks if complete remission is not achieved 1
• Begin tapering 2 weeks after complete remission is documented, not after the full 4-week minimum 1

This represents an important update from older protocols that required waiting the full 4 weeks even after early remission, recognizing the need to minimize glucocorticoid toxicity 1.

Tapering Schedule

Once remission is achieved, implement a slow taper over 24 weeks total duration: 1

• The taper should be gradual, reducing the dose incrementally over the 6-month period after remission 1
• The specific rate is not rigidly defined in guidelines, but reducing by approximately 10-20% of the current dose every 2-4 weeks is a reasonable approach based on the total 6-month tapering window 1
• Continue tapering until reaching a low maintenance dose or complete discontinuation by 6 months 1

Alternative Dosing Considerations

• Alternate-day dosing at 2 mg/kg (maximum 120 mg) is an acceptable alternative to daily dosing, particularly during the tapering phase 1
• Route and frequency can be individualized, though daily oral glucocorticoids are most commonly used 1

Critical Pitfalls to Avoid

Do not extend high-dose glucocorticoid treatment beyond 16 weeks, as this increases toxicity without improving outcomes 1. The evidence shows that patients who don't respond by 16 weeks are steroid-resistant and require alternative therapies 1.

Do not taper too rapidly. Studies in pediatric populations showed that shorter steroid courses result in significantly higher relapse rates (81% vs 59% at 2 years) and shorter remission durations 2. While adult-specific rapid taper data are limited, the guideline recommendation of 6 months reflects this concern 1.

Monitor for relapse during and after tapering. If relapse occurs, restart treatment with the same initial high-dose regimen used for the first episode 1.

Special Populations

For patients with relative contraindications to high-dose corticosteroids (uncontrolled diabetes, psychiatric conditions, severe osteoporosis), consider initial therapy with cyclophosphamide or calcineurin inhibitors instead 1.

Context-Specific Modifications

Lupus Nephritis

For lupus nephritis specifically, the tapering approach differs: 1

• Use intravenous methylprednisolone pulses (500-2500 mg total) followed by oral prednisone 0.3-0.5 mg/kg/day for up to 4 weeks 1
• Taper to ≤7.5 mg/day by 3-6 months 1
• This more aggressive taper reflects the different pathophysiology and the availability of concurrent immunosuppressive agents 1

Membranous Nephropathy (Class V)

For pure membranous lupus nephritis: 1

• Start with pulse methylprednisolone followed by prednisone 20 mg/day 1
• Taper to ≤5 mg/day by 3 months 1

The evidence base for adult MCD tapering protocols is limited, with most high-quality data derived from pediatric studies 1. The 6-month taper recommendation represents expert consensus balancing relapse risk against glucocorticoid toxicity 1.