What is the recommended tapering schedule for a patient taking 10 mg daily prednisolone over a four‑week period?

Tapering Prednisolone 10mg/day After 4 Weeks of Treatment

After 4 weeks at 10 mg/day prednisolone, reduce the dose by 1 mg every 4 weeks until complete discontinuation, administering the entire daily dose as a single morning tablet before 9 AM. 1, 2

Rationale for Slow Tapering Below 10mg

• Hypothalamic-pituitary-adrenal (HPA) axis suppression occurs in any patient receiving >7.5 mg daily for >3 weeks, making gradual withdrawal essential to allow adrenal recovery 1, 2
• Faster tapering below 10 mg is associated with higher risk of disease relapse and withdrawal symptoms (arthralgia, myalgia, malaise, fatigue) compared to the 1 mg every 4 weeks schedule 1, 2
• Research demonstrates that prednisolone causes dose-dependent HPA suppression, with 5 mg daily producing approximately 10% plasma cortisol suppression 3

Specific Tapering Schedule

Week-by-week reduction from 10 mg:

• Weeks 1-4: 10 mg daily
• Weeks 5-8: 9 mg daily
• Weeks 9-12: 8 mg daily
• Weeks 13-16: 7 mg daily
• Weeks 17-20: 6 mg daily
• Weeks 21-24: 5 mg daily
• Weeks 25-28: 4 mg daily
• Weeks 29-32: 3 mg daily
• Weeks 33-36: 2 mg daily
• Weeks 37-40: 1 mg daily
• Week 41+: Discontinue 1, 2

If 1-mg tablets are unavailable, use alternate-day dosing to achieve gradual reductions (e.g., alternate 10 mg/7.5 mg days to average 8.75 mg, then 10 mg/5 mg to average 7.5 mg) 1, 2

Dose Timing and Administration

• Take the entire daily dose as a single morning tablet before 9 AM to align with physiologic cortisol rhythms and minimize residual HPA-axis suppression 1, 2
• Single daily dosing is preferred over divided doses except for prominent night pain while on doses <5 mg 1

Monitoring Schedule

• Schedule follow-up visits every 4-8 weeks during the first year of tapering, then every 8-12 weeks in the second year 1, 2
• At each visit, assess:
  • Disease activity markers (ESR, CRP, or condition-specific laboratory tests) 1, 2
  • Symptoms of steroid withdrawal (arthralgia, myalgia, malaise, fatigue) 1, 2
  • Signs of adrenal insufficiency (weakness, orthostatic symptoms, weight loss, nausea, hyponatremia, hyperkalemia) 1

Managing Disease Relapse During Taper

If clinical symptoms recur:

1. Immediately return to the pre-relapse prednisolone dose and maintain for 4-8 weeks until disease control is re-established 1, 2
2. After re-stabilization, resume tapering by gradually decreasing to the dose at which relapse occurred over 4-8 weeks 1, 2
3. Consider adding a steroid-sparing agent (azathioprine 2 mg/kg/day, methotrexate, or mycophenolate mofetil) if multiple relapses occur or if difficulty tapering below 7.5 mg/day is anticipated 1, 2

Stress-Dosing Requirements

• During acute illness or physiologic stress while tapering or within 12 months of discontinuation, patients require supplemental glucocorticoids 1, 2
• For minor illness: Double the current prednisone dose for 3 days 1
• For moderate stress: Hydrocortisone 50 mg twice daily for 3 days 1, 2
• For major surgery or severe infection: Hydrocortisone 50-100 mg three times daily 1
• Provide written stress-dosing instructions and ensure patients carry an emergency glucocorticoid supply (medical alert bracelet recommended) 1

Disease-Specific Considerations

For autoimmune hepatitis (if applicable to your patient):

• The British Society of Gastroenterology recommends prednisolone 30 mg/day reducing to 10 mg/day over 4 weeks plus azathioprine 1 mg/kg/day as initial treatment 4
• If your patient is already on azathioprine and it has been established for 2-3 months, you may accelerate the taper: reduce by 5 mg each week until reaching 10 mg, then by 2.5 mg every 2-4 weeks 1
• Continue treatment for at least 2 years and at least 12 months after normalization of transaminases 4

For bullous pemphigoid (if applicable):

• The British Association of Dermatologists suggests reducing by 2.5 mg decrements at fortnightly intervals down to 10 mg daily, then by 1 mg each month 4

Common Pitfalls to Avoid

• Tapering too quickly below 10 mg leads to disease flare or symptomatic adrenal insufficiency; the 5 mg weekly reductions used for short courses are inappropriate after 4 weeks of therapy 1
• Failing to provide stress-dosing education may result in adrenal crisis during intercurrent illness 1, 2
• Not monitoring disease activity during tapering may miss early signs of relapse 1
• Discontinuing glucocorticoids based solely on symptom resolution without confirming HPA-axis recovery can lead to adrenal crisis 1

Long-Term Maintenance (If Needed)

For patients with recurrent relapses despite optimal tapering, maintaining an indefinite low-dose regimen (2.5-7.5 mg/day) is acceptable when therapeutic benefits outweigh risks; observational data indicate this provides effective disease control with an acceptable safety profile 1, 2