Prednisone Taper

Prednisone Taper – No Longer Needed for Short Course Corticosteroid Therapy: As a medical student and resident I remember hearing all of the attending physicians tell me about the best way to do a prednisone taper.  I still have older patients question why prednisone tapering is not recommended, because their old doctor always did a prednisone taper.  For those of you not familiar with prednisone, or corticosteroid treatment in general, prednisone is a commonly used, inexpensive, and quite potent corticosteroid.  Corticosteroids are distinctly different from the anabolic steroids of the Mitchell Report and Marion Jones infamy.  Corticosteroids are naturally occurring hormones produced by the adrenal cortex that are essential to our well being.  They serve to regulate glucose, protein and fat metabolism and function to reduce inflammation by blocking a key step in the inflammatory process and by inhibiting eosinophil (the primary allergic white blood cell) action, as well as other mechanisms.  Therapeutically corticosteroids like prednisone, dexamethasone, prednisolone, hydrocortisone and others are used in higher than naturally occurring amounts to reduce inflammation.  They are commonly used in attacks of asthma or bronchospasm, in severe acute arthritis, in head trauma or spinal cord trauma with swelling, in acute severe allergic reactions, in severe dermatitis, and for lots of other situations.  They are often injected directly into inflamed areas to reduce inflammation locally.

The big problem with use of high dose corticosteroid therapy is that it eliminates the demand on the adrenal glands to produce cortisol naturally. After the adrenal glands stop functioning to produce cortisol for a period of time, it takes them a while to resume producing normal amounts of cortisol.  It takes even longer to be able to respond to emergency situations where the body requires much higher amounts of cortisol.  In situations like major trauma, surgery, serious infections like pneumonia or pyelonephritis, or really any physically traumatic event the body requires cortisol in higher than usual amounts to cope effectively.  Lack of this adrenal response can lead to shock that fails to respond to fluid resuscitation and death.  This situation is seen clinically in two fairly common situations.  The most common situation is where a patient has been on therapeutic corticosteroid therapy in a dose sufficient to suppress the adrenal glands for a prolonged time and an acute emergent situation develops and the adrenals are not able to respond normally.  The other situation is when a patient has adrenal insufficiency, is on standard daily doses of corticosteroid replacement therapy, and becomes acutely ill or has major trauma.  In either of these situations it is critical to treat the patient with high dose corticosteroids, usually IV if the need is emergent, or orally if it surgery or acute illness is anticipated in order to prevent critical illness-related corticosteroid insufficiency.

Medrol Dose-Pak Seldom Needed Anymore

In order to prevent this situation for years we were taught to taper corticosteroid treatment after short term “burst” course treatments of prednisone.  Typically we would start moderately high dose of prednisone, say 60 mg for 3 days, then 40 mg for 3 days, then 20 mg for 3 days, then 10 mg for 3 days, then 5 mg for 3 days.  You can imagine there are innumerable variations on this theme.  A product is marketed to make this taper simple, the “medrol dosepak”  (see photo above). The dogma was always taper steroids to allow the adrenal gland to recover from the high dose therapy.  As with many things this was done because everyone knew it was the right thing to do, but nobody looked at it critically.  We have learned that the key to avoiding adrenal suppression prednisone side effects after a short course of prednisone therapy is not tapering corticosteroid therapy, but to keeping the course of therapy as short as possible.  Now we will often use 6o mg of prednisone daily for 7 days, and stop.  This is really safer than taking 10-21 days to taper off the high dose.

I want to make this perfectly clear.  If you have been treated with a course of prednisone, even in moderate or low doses, for more that about 3 weeks you are likely to need a prednisone taper.  Many experts would use the 3 week time frame for this, although some would use as little as 2 weeks, and others might allow up to 4 weeks or even more.  The way the prednisone is dosed makes little difference in the need to taper.  Longer doses of as little as 5-10 mg daily of prednisone require a taper to avoid the risk of adrenal insufficiency. Short courses of even very high doses of prednisone do not require a taper to avoid adrenal insufficiency. Some indications for prednisone benefit from a taper in dosage to avoid a flare in the disease process being treated, and this article is NOT meant to address a therapeutic taper to avoid recurrence or exacerbation of the underlying disorder, but rather just to avoid adrenal insufficiency.

DO NOT MISREAD THIS DISCUSSION.  IF YOU HAVE BEEN TREATED LONGER THAN ABOUT 2 WEEKS WITH PREDNISONE DISCUSS STOPPING WITH YOUR DOCTOR! YOU MAY NEED A TAPER!  YOU ALSO MAY NEED A THERAPEUTIC TAPER TO BEST TREAT YOUR CONDITION. 

It seems that the taper itself is mostly treatment at much higher than natural corticosteroid needs (roughly 5 mg daily of prednisone, or 20 mg daily of hydrocortisone).  For some illnesses even shorter bursts of treatment are effective.  In croup, a viral illness of young children a single IM dose of dexamethasone, or a 3 day burst of high dose prednisone or dexamethasone is quite effective.

In conditions where longer term treatment with corticosteroids is needed, a slow taper is critical.  Examples are many rheumatologic disorders like systemic lupus erythematosis, polymyalgia rheumatica, and other autoimmune disorders like Crohn’s disease and Ulcerative Colitis.  In these cases gradual tapers over weeks to months are needed, and patients are at risk of adrenal crisis for some time after stopping therapy.

The key to understand is that in burst courses of prednisone treatment unless there extenuating circumstances like diabetes or major psychiatric disorders, shorter courses at higher doses are much safer than longer courses or longer tapers.  Now instead of hearing every attending and senior resident preach their favorite way to taper burst courses of steroids, they should be debating how short a course of high dose prednisone they can use and still get a good response.

266 Responses to Prednisone Taper

  1. Jonathan: These are not typical side effects. If they are side effects they are more likely from prednisone itself rather than from the taper. Good luck. Dr. P.

  2. I’m on a 50-40-30-20-10 5 day burst for a skin rash. I’m on day 4 (20mg) and am getting muscle cramping in my arms, legs, and feet, tomorrow is my last day (10mg). Should I expect more of the same side effects? How long will they last typically with these short bursts?

  3. Donna,

    Your comment makes it unclear to me just what you’ve been taking and how long. I would not ask someone who had been taking prednisone 60 mg daily for just 2 days, and not on any other corticosteroids, to taper at all. Dr. P.

  4. I know I messed up. The only time I can walk around and work without pain is when I am on prednisone. I have been taking 60 mg/ day for about 12 weeks. I have been afraid to stop or reduce the dose because I know I will be seriously weak and tired and have too much arthritis pain to work. I was thinking about tomorrow taking 50mg instead of 60.

  5. Cheryl: Side effects are very subject to individual variation, you’ll have to see how it affects you. the 4 week course is long enough that you might need to taper more slowly at the end of treatment. DrP.

  6. Adrian: I deer to your dermatologist re how long to treat the rash. In general it is best to keep courses of prednisone as short as possible. This article addresses tapering of prednisone, not your issue here. DrP.

  7. Hi Dr. Pullen,

    I’m on Prednisolone 30mg for 7 days 15/15 after bfast/lunch due to rashes all over my body caused by bacterial / viral infection – we’ll my Derma could not just identify the reason.

    Anyway, today is my last day of taking Gupison, Rashes are finally clearing and less itchy especially at night.

    In case my Derma advises to stop it, will I suffer side effects?? I’m just concern that the rashes may flare up again?

  8. Given a prednisone burst. 40 mg for a week, 30 mg for a week, 20 mg for a week, 10 mg for a week. I have polymyositis and have taken much higher doses of prednisone in the past during a flare. My CKs are currently moving up (about 700 range) so I was prescribed prednisone to see if my numbers decrease. I am also currently taking leflunomide/azothioprine/meloxicam. My azothioprine was also so upped from 2 pills a day to 3. Will I have much for side effects? I am sure I will have insomnia and the mood swings…I forget about the weight and the moon face stuff.

  9. I was put on prednisone for mono 9 days ago with the dose of 10mg tablets. I was also put on clindamycin for 10 days. The directions for the prednisone said take 4 pills a day for 4 days, 2 pills a day for 4 days, 1 pill a day for 4 days and finally 1/2 pill a day for 4 days. The problem is I’m always anxious, have tight muscles especially on my left side, get flushed red like I’m hot but running no fever, my heart rate picks up for time to time, and cannot sleep but want to. Is this the prednisone and if so can I stop using it now cause I’m wearing out not sleeping?

  10. Dove: The symptoms you describe are common prednisone side effects. They should resolve off the prednisone. I would not taper your dose if you were my patient. DrP.

  11. Judy: I can think of no reason it is not safe to stop unless the underlying condition is so serious that stopping may risk that problem becoming worse. DrP.

  12. I was put on prednisone a dose of taking three tablets a day for three days then two for three days then 1 for three days at 20 mg for each tablet. I have only taken day 1 which is three tablets is it safe to stop since I only took one dose ,can’t sleep, sugar went up high ,and my irregular heart beat acted up.am I safe to stop

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