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.

220 Responses to Prednisone Taper

  1. Thank Dr. Pullen for helping to educate and support self advocacy!! I took my 9 yr. old back to see the pediatrician and given my assurances of careful oversight and our specific situation (complete clearing of rash prior to steroid use -treatment was for swollen fingers- plus multiple unrelated skin wounds) we stopped oral steroid treatment after three days. We kept on with benadryl for 3 days, treated the wounds with topical prescription antibiotic and now over a week later he has recovered wonderfully. Note that we have knowledgeable experience with these rashes, washed all clothing – bedding – shoes and rash sites thoroughly and continue to oversee his health closely.

  2. Jen: In my experience with poison ivy/oak if you stop the prednisone after just 2 days of treatment the symptoms will recur, and the approx 2 week course recommended by your pediatrician is similar to what I’d have recommended. DrP.

  3. Dr. Pullen, After _2_ days of twice daily treatment of Oral Prednisolone (10mL of 15mg/mL soln) my 9yr old’s finger swelling due to Poison Oak is well controlled and I’ve tried to get the pediatrician to reduce the recommended schedule (4 day treatment + 9 day taper). Please do you have a reference to support your assertions – and do you believe they are applicable to this case?? We managed 6 days with oral benadryl only, so after only two days of steroid I would much prefer to stop this drug!
    Thank you for sharing your expertise.

  4. Rob: the details of any taper need to be individualized to each patient. Work closely with your doc to assure you do OK with your taper. DrP.

  5. I was put on dexmethazine taper. Once getting to 12 mil my doc said I could stop because of the side effects. I ended up in the hospital with adrenal crises shock. The hospital gave me 100 mil of hydrocortisone then down to 50 mi then 25 mil before starting me on a prednisone taper. Does this taper sound ok. 50 mil for 2 days 40 mil for 2 days 30 mil for 2 days 10 mil for 2 days 5 mil for 2 days and off.

  6. Dr pullen

    Pills scare tge luving hell out of me and with all this taper talk and the vad things tfat could happen if you dont almost makes me not want to take this crap

    Here iswhat my doc prescribed

    Prednisone each pill 20 milligrams

    Day 1 & 2 60 mg/ day
    Day 3 & 4 50 mg / day
    Day 5 & 6 40 mg / day
    Day 7 & 8 30 mg / day
    Day 9 & 10 20 mg /day
    Day 11& 12 10 mg / day done

    Thos whole adrenal ctap itcwas talking about got me all freaked out

  7. I highly disagree with no taper for a short period. I was given prednisone at 40 mg/day for 7 days for a swollen uvula. After stopping medication the following happened: My uvula swole up twice, my knee started hurting severely without any accident, I had a severe stomach virus and puked for three days straight, I lost 12 pounds of muscle mass which i have not gained back, i had thrush for about three months, i had to drop my classes because i could not think, i have sciatica, depression. It has been a year and it still haunts me. A taper should have been used. I will never take any meds ever again. I would like to see any doctor try and take prednisone for a week without taper and just see what happens.

  8. After three months on a very high dose of prednisone for severe chronic idiopathic urticaria and angiodedema, (60/day mg at first, then eventually down to 20 mg), I gained 35 lbs, had edema in my legs and feet and severe knee pain from the extra weight, and couldn’t sleep at all. I’was able to taper down gradually to 10 mg, then 5 mg daily over the course of a month, lowering my daily dose by 1 mg every week without recurrence of my symptoms. But ever since I’ve been slowly tapering down from that point, the side effects of withdrawal have been completely debilitating and ghastly. My doctor suggested reducing the dose by as little as .25 mg every two weeks to minimize the effects, but even with this minimal reaction and slow taper, I feel like death for a good 5 days after each reduction. Can you recommend something (anything!!) that would help the horrible withdrawal symptoms? Feeling this way is almost worse than the condition that put me on prednisone to begin with, or the horrible side effects of being on prednisone at a high dose. Other than a low salt, low sugar healthy diet and plenty of water and regular exercise (all of which I do except for the days when withdrawal symptoms keep me glued to the couch and sobbing), are there specific foods, herbs or dietary supplements that would help with the withdrawal? I’ve already lost 15 lbs on the lower dose through vigilant diet and exercise, though it’s come off agonizingly slowly because of the medication. I’m ready to reclaim my life, but at 3 mg now, at this schedule of a .25 mg reduction every 2 weeks, I’m looking at losing three more months to this agonizing slow taper. There are days when I just want to die rather than feel like this. Please give me advice on how to help survive this process and hope that it will get better. Thank you.

  9. Arlene, Sorry not to be able to give individual advice on the blog. Consider asking your Family physician or internist if your dermatologist is not helpful. DrP.

  10. I was prescribed prednisone as follows: 30 mg for 2 weeks, then 20 mg for 2 weeks, then 10 mg for 2 weeks (no taper after that). My dermatologists prescribed it because I was to start accutane a week after starting prednisone in order to try to avoid an initial breakout from accutane. After being on 30 mg for 3 days of insomnia I called doc to see if I can lower to 20mg in which I did. I still couldn’t sleep and my heart was racing as well as my head was throbbing at night (not a headache though), so I lowered my dose to 10mg after one week. I have taken it for three days now and still having trouble sleeping, neck pain, heart racing, and head throbbing! I want to see if I can just stop it completely now or do I have to taper and if so what do you recommend? I’ve been on prednisone for a total of 13 days. (30 mg for 3 days, 20mg for 7 days, and 10 mg for 3 days) Please help!! My dermatologist nurse hasn’t been at all helpful😖

  11. Irma: What you describe does not appear unusual. Each individual may have specific circumstances that make me unwilling to give specific advice on the blog. Good luck. DrP.

  12. October 31 I took a bubble pack of Medrol. 11/9 I was given 5mg over period of three days3-2-1- taper) 11/11 I was prescribed 3-5 mg for 3 day, 2 5 mg for 3 days and 1 5 mg for 3 days. is this too much prednisone I have bronchitis, an ear infection and some wheezing x-ray showed no pneumonia

  13. This is a question you need to coordinate with your physician. You’ve been on corticosteroids long enough that physician supervision seems appropriate. Good luck. DrP.

  14. I’ve been on prednisone for about 6 weeks due to authorities pain from lupus. Started at 20 mg then went up to 40 mg for about 2 weeks then went back down to 30 mg for 2 weeks now on 20 mg for about a week….had some withdrawal symptoms…I can’t stand being on it any longer! I am thinking of going down to 15 mg for 3 days, then 10mg for 3 days, then 5 mg for 3 days, then none. I’m also taking 600 mg of calcium and vitamins D for help with joint pain. Does this sound reasonable for the length of time I’ve been on prednisone?

  15. Harry: After two weeks on a higher dose of prednisone you can probably just drop back to your 4 mg safely, but you need to ask your personal physician as there may be other issues to consider. I cannot give individual medical advice on the blog site. Good luck. DrP.

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