What is an appropriate taper schedule for prednisone 60 mg daily after a three‑week course?

Prednisone Taper After 60mg Daily for Three Weeks

After a three-week course of prednisone 60 mg daily, taper rapidly to 10 mg daily over 4-8 weeks, then reduce by 1 mg every 4 weeks until discontinuation.

Rapid Initial Taper Phase (Weeks 4-7 to 4-11)

The most critical principle is that high-dose prednisone (≥30 mg/day) should be reduced quickly to minimize adverse effects while maintaining disease control. 1

• Reduce from 60 mg to 10 mg daily over 4-8 weeks using the following framework: 1
  • For doses >50 mg/day: decrease by 10 mg every 1-2 weeks 2
  • For doses 50-25 mg/day: decrease by 5-10 mg every 1-2 weeks 2
  • For doses 25-15 mg/day: decrease by 2.5 mg every 2-4 weeks 2

Example rapid taper schedule:

• Week 4: 50 mg daily
• Week 5: 40 mg daily
• Week 6: 30 mg daily
• Week 7-8: 25 mg daily
• Week 9-10: 20 mg daily
• Week 11: 15 mg daily
• Week 12: 10 mg daily

Slow Maintenance Taper Phase (After Reaching 10 mg)

Once you reach 10 mg daily, the taper must slow dramatically to prevent adrenal insufficiency and disease relapse. 1

• Reduce by 1 mg every 4 weeks (or equivalent schedules like 2.5 mg every 10 weeks using alternate-day dosing) 1
• For doses <15 mg/day: reduce by 1.25-2.5 mg every 2-6 weeks 2
• Below 5 mg daily, consider even slower tapering (every 4-6 weeks per dose reduction) as adrenal suppression risk is highest 2

Critical Context: Is Tapering Even Necessary?

For short courses (≤3 weeks), the evidence suggests tapering may not be medically necessary to prevent adrenal insufficiency or rebound. Multiple randomized controlled trials in acute asthma found no difference in relapse rates or adrenal suppression between abrupt discontinuation and tapering after 7-10 days of treatment. 3, 4, 5, 6

However, after three weeks at 60 mg daily, tapering is prudent because:

• Three weeks approaches the threshold where HPA axis suppression becomes clinically significant 7
• The dose of 60 mg is high enough to warrant gradual reduction 2, 8
• Adrenal suppression is anticipated in any patient receiving >7.5 mg daily for >3 weeks 2

Monitoring and Safety

Follow-up visits should occur every 4-8 weeks during the first year of tapering to monitor for: 1

• Disease relapse (return of symptoms)
• Steroid withdrawal symptoms (fatigue, myalgias, arthralgias)
• Adverse effects (hyperglycemia, hypertension, mood changes)

Initiate bone protection immediately: 2

• Calcium 1,200-1,500 mg/day
• Vitamin D 800-1,000 IU/day
• Consider bisphosphonates for men ≥50 years on long-term therapy

Common Pitfalls to Avoid

• Never stop abruptly after three weeks at 60 mg daily - while studies show short courses can be stopped without taper, three weeks is the borderline where HPA suppression becomes concerning 8, 7
• Don't taper too slowly in the high-dose range (>25 mg) - this unnecessarily prolongs exposure to adverse effects 2
• Don't taper too quickly below 10 mg - this is where adrenal insufficiency and disease relapse are most likely 1
• Avoid split dosing - use single morning doses to minimize HPA suppression, except for breakthrough night symptoms below 5 mg daily 1, 8
• If relapse occurs during taper, increase back to the pre-relapse dose and hold for 4-8 weeks before attempting to taper again 1