I’ve been taking prednisone 5 mg daily for over 3 weeks; how should I taper or discontinue it to prevent adrenal insufficiency?

Tapering Prednisone 5 mg Daily After 3 Weeks to Prevent Adrenal Insufficiency

After only 3 weeks of prednisone 5 mg daily, you can stop abruptly without tapering—the risk of clinically significant adrenal suppression requiring a taper is minimal at this dose and duration. 1, 2

Understanding Your Risk

• HPA-axis suppression should be anticipated in patients receiving >7.5 mg prednisolone-equivalent daily for >3 weeks, but your dose of 5 mg falls below this threshold 1
• At 5 mg daily for 3 weeks, the likelihood of developing adrenal insufficiency requiring stress-dose coverage is low, though not zero 1, 3
• The EULAR guideline notes that adrenal suppression risk cannot be completely excluded even with alternate-day therapy or doses below 7.5 mg, but emphasizes that risk increases substantially with higher doses and longer duration 1

Recommended Approach

Stop the prednisone without tapering after 3 weeks at 5 mg daily. 1, 2

Why No Taper Is Needed

• The FDA label states that "if after long-term therapy the drug is to be stopped, it is recommended that it be withdrawn gradually rather than abruptly"—but 3 weeks does not constitute long-term therapy 2
• Studies show that approximately one-third to one-half of patients taking 5-20 mg prednisolone daily develop some degree of HPA suppression, but this typically occurs with chronic use (months to years), not 3 weeks 3, 4
• Research in children with rheumatic diseases found that adrenal suppression occurred after a median of 39.6 weeks of glucocorticoid therapy, not after short courses 5

Critical Monitoring After Discontinuation

Even though you can stop abruptly, remain vigilant for symptoms of adrenal insufficiency for 2-4 weeks after stopping, including: 6, 7

• Severe fatigue or weakness that worsens progressively
• Nausea, vomiting, or inability to eat
• Dizziness or lightheadedness when standing (orthostatic hypotension)
• Unexplained weight loss
• Confusion or altered mental status

When to Seek Immediate Medical Attention

Go to the emergency department immediately if you develop: 7, 6

• Severe vomiting or diarrhea preventing oral intake
• Profound weakness with inability to stand
• Confusion, altered mental status, or loss of consciousness
• Persistent hypotension or shock-like symptoms
• Severe abdominal pain with peritoneal signs

Emergency Treatment Protocol

• If adrenal crisis is suspected, treatment must never be delayed for diagnostic testing—immediate IV hydrocortisone 100 mg plus rapid saline infusion at 1 L/hour is required 7, 6

Special Circumstances Requiring Stress-Dose Coverage

If you develop a significant physiological stress within 4-8 weeks after stopping prednisone (such as severe infection, trauma, or surgery), inform your physician that you recently discontinued corticosteroids: 1, 8

• Respiratory infections with fever are the most common trigger, accounting for ~50% of adrenal crises 8
• You may need temporary stress-dose glucocorticoid coverage (typically hydrocortisone 50-100 mg IV or doubling your previous oral dose) 1, 8
• The guideline states: "if in doubt, give" stress-dose steroids, as short-term supplementation causes no harm but omission can be fatal 8, 9

Common Pitfall to Avoid

• Do not confuse short-term use (3 weeks) with chronic use (months to years)—the tapering recommendations in guidelines and the FDA label apply primarily to patients on prolonged therapy 1, 2
• Do not assume you need formal adrenal function testing (morning cortisol or ACTH stimulation test) after only 3 weeks at 5 mg daily—testing is reserved for patients with longer exposure or higher doses who develop concerning symptoms 7, 6

If Symptoms Develop After Stopping

Should you experience persistent fatigue, nausea, or other concerning symptoms 1-4 weeks after discontinuation: 7, 6

• Measure early-morning (8 AM) serum cortisol and plasma ACTH
• A morning cortisol <5 µg/dL with low or inappropriately normal ACTH suggests secondary adrenal insufficiency
• A cortisol >18-20 µg/dL effectively rules out adrenal insufficiency
• Intermediate values (5-18 µg/dL) require cosyntropin stimulation testing for definitive diagnosis 7, 6

The bottom line: after 3 weeks at 5 mg daily, stop without tapering, but remain alert for symptoms of adrenal insufficiency during the subsequent month and seek immediate care if severe symptoms develop. 1, 2, 6