What is the recommended taper schedule for an adult who has been taking 30 mg oral prednisone daily for several weeks?

Prednisone Tapering from 30 mg Daily

For an adult on 30 mg prednisone daily for several weeks, reduce to 10 mg/day within 4-8 weeks, then taper by 1 mg every 4 weeks until discontinuation, while monitoring closely for disease relapse and adrenal insufficiency. 1, 2, 3

Initial Rapid Taper Phase (Weeks 1-8)

Reduce from 30 mg to 10 mg/day over 4-8 weeks using the following schedule:

• Week 1-2: 25 mg daily (decrease by 5 mg) 1, 3
• Week 3-4: 20 mg daily (decrease by 5 mg) 1, 3
• Week 5-6: 15 mg daily (decrease by 5 mg) 1, 3
• Week 7-8: 10 mg daily (decrease by 5 mg) 1, 3

This initial phase can be completed in as little as 4 weeks if disease activity remains well-controlled, or extended to 8 weeks if there are concerns about relapse or the patient has risk factors for flare. 4

Slow Maintenance Taper Phase (After reaching 10 mg/day)

Once at 10 mg/day, reduce by 1 mg every 4 weeks until complete discontinuation. 4, 1, 2, 3 This slower pace below 10 mg is critical because:

• Small dose decrements can trigger significant withdrawal symptoms and adrenal insufficiency 1, 2
• The hypothalamic-pituitary-adrenal (HPA) axis requires gradual recovery time 1
• Disease relapse risk increases with faster tapering 4

Example schedule from 10 mg to discontinuation:

• Weeks 9-12: 9 mg daily
• Weeks 13-16: 8 mg daily
• Weeks 17-20: 7 mg daily
• Continue this pattern until discontinuation 1

If 1 mg tablets are unavailable, use alternate-day dosing (e.g., 10/7.5 mg on alternating days) to achieve gradual reductions. 4

Dosing Administration

Administer the entire daily dose as a single morning dose before 9 AM. 4, 1, 2, 3 This approach:

• Minimizes HPA-axis suppression by aligning with physiologic cortisol rhythms 4, 1
• Reduces adrenal suppression compared to divided dosing 5
• Is more convenient and improves compliance 5

The only exception is prominent night pain while tapering below 5 mg daily, where split dosing may be considered. 4

Monitoring During Taper

Schedule follow-up visits every 4-8 weeks during the first year of tapering, then every 8-12 weeks in the second year. 4, 1, 2, 3 At each visit assess:

• Disease-specific activity markers (ESR, CRP, or condition-specific labs) 4, 1
• Signs of adrenal insufficiency: fatigue, weakness, orthostatic symptoms, weight loss, nausea, hyperpigmentation 1
• Serum sodium and potassium to detect mineralocorticoid deficiency 1
• Blood glucose if diabetic or at risk 3
• Symptoms of steroid withdrawal: arthralgia, myalgia, malaise 4

Managing Disease Relapse

If symptoms recur during tapering, immediately return to the pre-relapse dose and maintain for 4-8 weeks until disease control is re-established. 4, 1, 2, 3 Then:

• Resume tapering by gradually decreasing to the dose at which relapse occurred over 4-8 weeks 4
• Consider a slower subsequent taper rate (e.g., 0.5-1 mg every 4-6 weeks) 1
• Evaluate for addition of steroid-sparing agents if multiple relapses occur 4, 1

Stress Dosing Requirements

Any patient receiving >7.5 mg daily for >3 weeks requires supplemental glucocorticoids during acute illness or surgery due to HPA-axis suppression. 1, 2, 3 Specific protocols:

• Minor illness/moderate stress: Double the current prednisone dose for 3 days 1, 3
• Moderate stress (patient on 10 mg daily): Hydrocortisone 50 mg twice daily for 3 days 1, 2
• Severe stress/major surgery: Hydrocortisone 50-100 mg three times daily 1, 2

Provide written stress-dosing instructions and consider a medical alert bracelet identifying adrenal insufficiency risk. 1, 2

Steroid-Sparing Agents

Consider adding azathioprine (2 mg/kg/day), methotrexate, or mycophenolate mofetil early if:

• High risk of relapse or prolonged therapy anticipated 4
• Risk factors for glucocorticoid-related adverse events (diabetes, osteoporosis, hypertension, cardiovascular disease) 4
• Difficulty tapering below 7.5 mg/day 4, 1
• Multiple relapses during previous taper attempts 4, 1

When azathioprine is established (after 2-3 months), the prednisone taper can be accelerated: reduce by 5 mg every week until reaching 10 mg/day, then by 2.5 mg every 2-4 weeks. 4, 1

Critical Pitfalls to Avoid

• Tapering too quickly is the most common error and leads to disease flare or symptomatic adrenal insufficiency 1, 3
• Failing to provide written instructions about the exact daily dose for each phase of the taper 1, 3
• Not educating patients about stress dosing for sick days, which can precipitate adrenal crisis 1, 2, 3
• Accelerating the taper if steroid-sparing agents started <2-3 months ago, as therapeutic levels may not be established 1
• Discontinuing steroids based solely on symptom resolution without confirming HPA-axis recovery 1

Special Considerations

For patients with recurrent relapses despite optimal tapering, indefinite low-dose maintenance (2.5-7.5 mg/day) is acceptable when benefits outweigh risks. 4, 1, 2 This strategy has demonstrated effective disease control with acceptable safety profiles in long-term observational studies. 4, 6