What is the recommended tapering regimen for a patient who has been taking prednisone at an incorrect dose of 80 mg daily for 4 days, then missed a dose, and is now out of medication, given that her poison ivy is responding well to treatment?

From the Guidelines

I recommend tapering the prednisone as follows: 40 mg daily for 2 days, then 30 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 completely, as the patient has been taking a high dose of 80 mg daily for 4 days and then 80 mg again on the fifth day, which is double the intended dose of 40 mg daily. According to the study by the Society for Immunotherapy of Cancer (SITC) toxicity management working group 1, if symptoms improve, it is recommended to taper corticosteroid over 4–8 weeks or until grade 1.

Since the poison ivy is improving well, a gradual taper is appropriate to prevent adrenal suppression that can occur with abrupt discontinuation of high-dose steroids. The body naturally produces about 5-7 mg of cortisol daily, and taking high doses of prednisone for more than a few days can suppress this natural production. A gradual taper allows the adrenal glands to resume normal function.

Some key points to consider during the taper include:

• The patient should take the medication in the morning to mimic the body's natural cortisol rhythm
• The patient should be advised that common side effects during the taper may include mild fatigue, body aches, or mood changes as the body readjusts
• Monitoring for any signs of adrenal insufficiency, such as severe fatigue, dizziness, or nausea, is crucial during the taper period, as recommended by the SITC toxicity management working group 1.

It is essential to note that the SITC toxicity management working group recommends tapering corticosteroids over 4–8 weeks or until grade 1 if symptoms improve 1, which supports the recommended tapering schedule.

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If after long-term therapy the drug is to be stopped, it is recommended that it be withdrawn gradually rather than abruptly Although it has been shown that there is considerably less adrenal suppression following a single morning dose of prednisolone (10 mg) as opposed to a quarter of that dose administered every 6 hours, there is evidence that some suppressive effect on adrenal activity may be carried over into the following day when pharmacologic doses are used The initial dosage should be maintained or adjusted until a satisfactory response is noted. If after a reasonable period of time there is a lack of satisfactory clinical response, PredniSONE should be discontinued and the patient transferred to other appropriate therapy IT SHOULD BE EMPHASIZED THAT DOSAGE REQUIREMENTS ARE VARIABLE AND MUST BE INDIVIDUALIZED ON THE BASIS OF THE DISEASE UNDER TREATMENT AND THE RESPONSE OF THE PATIENT After a favorable response is noted, the proper maintenance dosage should be determined by decreasing the initial drug dosage in small increments at appropriate time intervals until the lowest dosage which will maintain an adequate clinical response is reached.

The patient has been taking 80 mg of prednisone per day for 5 days. To taper her down, the dosage should be decreased gradually.

• Tapering schedule: Decrease the dosage by 10-20 mg every 1-2 days until reaching a dose of 20-30 mg per day, then decrease by 5-10 mg every 1-2 days until reaching the lowest effective dose or discontinuing the medication.
• Monitoring: The patient's clinical response and potential side effects should be closely monitored during the tapering process.
• Individualization: The tapering schedule may need to be adjusted based on the patient's individual response and disease status 2, 2.

From the Research

Tapering Prednisone for Poison Ivy Treatment

• The patient has been taking prednisone incorrectly at 80 mg (4 tabs q day instead of 40 mg Q day) for 4 days, missed a day, and then took 80 mg again before running out of medication 3.
• Given that the poison ivy is doing well, tapering the prednisone dose is necessary to avoid potential side effects such as adrenal insufficiency 4, 5.
• A study on poison ivy treatment suggests that a longer course of prednisone (15 days) may be more effective in reducing the need for additional medications and return visits to the doctor 3.
• However, another study found that shorter durations of oral corticosteroids (less than 14 days) were associated with increased risk of return visits to healthcare clinicians 6.

Recommended Tapering Schedule

• Based on the available evidence, a tapering schedule of 30 mg daily for 2 days, 20 mg daily for 2 days, 10 mg daily for 2 days, and 5 mg daily for 4 days could be considered 3.
• It is essential to monitor the patient's condition and adjust the tapering schedule as needed to avoid adrenal insufficiency and other potential side effects 4, 5, 7.
• The patient's response to the tapering schedule should be closely monitored, and adjustments made accordingly to ensure a safe and effective reduction in prednisone dose.