From the Guidelines
I recommend tapering the prednisone gradually to avoid adrenal suppression, with a suggested taper of 40 mg daily for 2 days, then 20 mg daily for 2 days, then 10 mg daily for 2 days, and finally 5 mg daily for 2 days before stopping, based on the most recent guideline from BSR/BHPR 2021 1. The patient has taken a high dose of prednisone (80 mg daily) for a relatively short period (5 days), and since the poison ivy is improving, this taper should adequately control the skin condition while safely withdrawing the steroid.
- The tapering regimen is based on the BSR/BHPR 2021 guideline, which recommends glucocorticoids usually given as daily oral prednisolone, initially at high doses (1 mg/kg up to 60 mg) with dose rapidly reduced to 15 mg prednisolone at 12 weeks 1.
- The prescription should be written for prednisone 20 mg tablets with instructions to take the appropriate number of tablets to achieve each dose level.
- The patient should be advised that abrupt discontinuation of prednisone after high-dose therapy can lead to adrenal insufficiency with symptoms like fatigue, weakness, nausea, and hypotension.
- It is essential to counsel the patient to take medications exactly as prescribed in the future to avoid similar situations.
- The BSR 2017 guideline also provides a tapering regimen, which recommends tapering 10 mg every 2-4 weeks until 20 mg/day, then taper dose 2.5-5.0 mg every 2-4 weeks until complete withdrawal 1, but the BSR/BHPR 2021 guideline is more recent and provides a more specific tapering regimen.
From the FDA Drug Label
If after long-term therapy the drug is to be stopped, it is recommended that it be withdrawn gradually rather than abruptly
- The patient has been taking a high dose of prednisone (80 mg/day) for 5 days and is now out of medication.
- To taper her down, it is recommended to gradually reduce the dose to prevent abrupt withdrawal symptoms.
- A possible tapering schedule could be:
- 60 mg/day for 1-2 days
- 40 mg/day for 1-2 days
- 20 mg/day for 1-2 days
- 10 mg/day for 1-2 days
- then stop
- However, the exact tapering schedule should be individualized based on the patient's response and clinical status 2.
- It is also important to monitor the patient closely for any signs of withdrawal symptoms or disease exacerbation.
From the Research
Tapering Prednisone
To taper the patient down from 80 mg of prednisone, consider the following:
- The patient has been taking a high dose of prednisone (80 mg) for 5 days, which increases the risk of adrenal insufficiency 3, 4, 5.
- The patient is now out of prednisone, so a tapering regimen should be started as soon as possible to minimize the risk of adrenal insufficiency.
- There is no one-size-fits-all approach to tapering prednisone, and the regimen should be individualized based on the patient's response 5.
- A common approach is to taper the dose by 5-10 mg every 3-5 days, but this may need to be adjusted based on the patient's symptoms and response to the taper 4.
Considerations for Tapering
When tapering the patient's prednisone dose, consider the following:
- The patient's symptoms, such as fatigue, weakness, and nausea, which can indicate adrenal insufficiency 6.
- The patient's basal cortisol levels, which can help determine the risk of adrenal insufficiency 6.
- The use of adrenal gland testing, such as the short 250 μg corticotropin test (SST), to confirm adrenal suppression 4, 6.
- The patient's overall health status, including any comorbidities, which can affect the risk of adrenal insufficiency 4, 5.
Tapering Regimen
A possible tapering regimen for this patient could be:
- 60 mg/day for 2-3 days
- 40 mg/day for 2-3 days
- 20 mg/day for 2-3 days
- 10 mg/day for 2-3 days
- 5 mg/day for 2-3 days
- Discontinue prednisone
Note: This is just a sample tapering regimen and should be adjusted based on the patient's response and symptoms. It is also important to monitor the patient's adrenal function and adjust the tapering regimen as needed 3, 4, 5, 6.