Stop the Steroid Taper Immediately and Return to the Pre-Taper Dose
When CRP rises during a planned glucocorticoid taper—from 22 mg/L to 59 mg/L in your case—you must immediately stop the taper and return to the dose at which the patient was stable (14 mg daily), because this represents active disease flare that requires re-establishment of control before any further dose reduction. 1
Why the Rising CRP Mandates Stopping the Taper
A CRP increase from 22 to 59 mg/L during steroid weaning signals that the underlying inflammatory process (either the rheumatoid arthritis or residual infection/inflammation from the recent pneumonia and bowel obstruction) is not adequately suppressed at the current dose 1
The European League Against Rheumatism explicitly recommends that if disease flare occurs during tapering, you must return immediately to the pre-relapse dose and maintain it for 4–8 weeks until disease control is re-established 1
Continuing to wean steroids in the face of rising inflammatory markers risks precipitating a full disease flare, prolonging the patient's illness, and potentially requiring even higher steroid doses to regain control 1
Immediate Management Steps
Increase prednisolone back to 14 mg daily (the dose at which CRP had fallen to 22) and hold at this level 1
Maintain 14 mg daily for 4–8 weeks while monitoring clinical symptoms and inflammatory markers every 2–4 weeks 1
Investigate the cause of the CRP rise:
- Assess for recurrent infection (repeat chest imaging, blood cultures if febrile, abdominal imaging if bowel symptoms recur)
- Evaluate RA disease activity (joint examination, patient global assessment)
- Check for other inflammatory complications 1
Only resume tapering once:
- CRP returns to the previous low level (≤22 mg/L) and remains stable for at least 4 weeks
- Clinical symptoms are controlled
- Any intercurrent infection has fully resolved 1
Modified Tapering Strategy After Re-Stabilization
When you do restart the taper, use a slower schedule than the original 2 mg every 3 days, which was too aggressive 1
The recommended approach after reaching 10 mg/day is to reduce by only 1 mg every 4 weeks, not 2 mg every 3 days 1
For this patient who has already demonstrated difficulty tapering, consider:
- Reducing by 1 mg every 4–6 weeks (slower than standard)
- Monitoring CRP and ESR at each dose reduction
- Holding at any dose where symptoms or markers worsen 1
Critical Distinction: Disease Flare vs. Infection
The rising CRP could represent either:
- RA flare as steroids are withdrawn (most likely given the maintenance dose was only 7 mg)
- Recurrent or persistent infection (pneumonia or intra-abdominal)
- Both simultaneously
Before attributing the CRP rise solely to RA and continuing high-dose steroids long-term, you must actively exclude ongoing infection with repeat imaging and clinical assessment, because immunosuppression from 14 mg prednisolone significantly increases pneumonia risk (hazard ratio 2.1 for doses 5–10 mg/day) 2
Long-Term Steroid-Sparing Strategy
This patient's difficulty tapering below 14 mg suggests they may need a steroid-sparing agent 1
Consider adding or optimizing a DMARD (azathioprine 2 mg/kg/day, methotrexate, or mycophenolate mofetil) once acute issues resolve, as these agents allow successful steroid reduction in patients with recurrent flares 1, 3
The goal remains to taper to ≤7.5 mg/day long-term or discontinue entirely, but this requires adequate disease control with steroid-sparing therapy 1
Common Pitfall to Avoid
Do not continue the planned taper "on schedule" simply because it was written in the discharge plan—inflammatory markers and clinical status always take precedence over a predetermined tapering schedule 1
The original plan to wean by 2 mg every 3 days was appropriate for a short steroid course, but this patient's rising CRP demonstrates they are not ready for that rate of reduction 1