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.

183 Responses to Prednisone Taper

  1. Cindy: 16 days, though a bit longer than a classic “short” or “burst” course of prednisone is still unlikely to be long enough to lead to significant adrenal suppression. I don’t give specific advice on this blog. You should ask your primary physician about your specific circumstances but in most cases I’d not taper after a 16 day course of prednisone. DrP.

  2. Dr. Pullen,

    About three weeks ago I developed the hives from an allergic reaction to amoxicillin. The doctor treating me at the time prescribed a 4 Mg dose pack of methylpredinisone to be tapered over the next 6 days along with diphenhydramine and Ranitidine. The following day I followed up with a dermatologist at which point she instructed I finish taking day 2 of the methylpredinsone and stop taking the other two meds. She then prescribed Predinisone with a 40 mg for 5 days then 20 mg for five days. After this treatment, I was to continue with the methylpredinsone treatment for the remaining 4 days. I followed these instructions, however, on day 8 of the 20 mg per day Predinsone treatment I ended up in the ER because my blood pressure was really high, my heart rate was irregular and I would wake up from my sleep grasping for air. The ER doctor treated me for an allergic reaction then prescribed a 60 mg per day for 5 days Predinsone treatment and told me to stop the other treatment. There was nothing mentioned about tapering off the Predinsone after the 5 day treatment. While I’ve been on the Predinsone and since I went off of it, I have been experiencing the classic side effects of this drug. So, in short, my question is do I need a taper after being on Predisone for 16 days? (Dosage total 44 mg between the first two days; 40 mg. for 5 days; 20 mg for 4 days; 60 mg for 5 days)Any advice you can give will be most appreciated.

  3. In my case, years ago I had been getting hives, which I believe to have been “Delayed pressure urticarial.” I went to an allergist b/c I wanted to go to a wedding and wear high heels. He gave me a low-dose of prednisone, 5 mg per day for about five days and told me to just stop it cold turkey. Within a few hours I went into anaphylactic shock. …I had gotten hives in my mouth and throat, all over my body, was lightheaded, and sensitive to light. He had to give me an injection of epinephrine. So was this an allergy to the prednisone? The hives that brought me to the allergist stayed with me for over three years. I have put prednisone on my allergy list.

  4. This is excellent information! I am a pharmacist but haven’t practiced clinically in many years… I was concerned that my doctor didn’t taper my prednisone dose (for brachial neuritis) and this gave me the rhyme to his reason. (in the detail I needed) Thank you.

  5. Hi,
    I recently was treated for anaphylactic shock after having Naproxen following a simple laparoscopy surgery. I didn’t know I was allergic, it was my first time taking Naproxen. My doctor gave me 50mg of Prednisone for 5 days. But there is no taper. Is it okay to just stop immediately ? I’m nervous about side-effects.

  6. Louise: Thanks for the comment. You are right, prednisone is indispensable in cases like yours, and the taper process is important and takes individual attention as you are obviously getting. Good luck. DrP.

  7. Great information Dr. Pullen. Thought I would post some positive info.,I have been dealing with Polymayalgia/Giant Cell Arteritis for almost 3 years now. We tried tapering off a few times but ESR rates rose again, i have been on quite a high dosage of Prednisone for most of the time but I am now in the process of a slow & gradual tapering off and it seems to be going well have to go for ESR test again but from how I am feeling I am pretty confident it will be good. I sure hope so, 3 years is a long time. Horrible drug but on the other side of the coin where would we be without it. I have excellent care, I do a lot of research, go to work every day even if for just an hour or two, and I try hard to keep a really positive attitude although I do,have the occasional ‘pity party’.
    I have been tapering off starting with 1 1/4 approximately (I cut a 5 mg in 4) over 2 weeks, I am now at 16 1/4 per day tomorrow I will go to 15 and we will see where ESR test is at. If how I feel is any indication it should be decent.
    Anyway just thought it would be nice for people to hear some positive news, as you say the tapering is different in every case. And again thank you for the great advice.

  8. My husband has Lupus (SLE) his at his last clinic appointment his consultant changed some medications and gave him Prednisolone 7mg tapering by 1 mg every 4 weeks. We were confused by this and queried it after the consult. We have now discovered that the consultant was not aware that he had previously reduced and stopped steroids (about 9 months ago) and this regime was to get him off what she thought was long term low dose steroid use. He has been taking 7mg for 1 week only. Is it safe for him to stop without tapering? Thank you

  9. Dylan: Your situation seems complex and challenging. You need to consult your physician to work through this decision making process. It is not a situation where you should try to experiment with dose changes yourself. Good luck. DrP.

  10. Hello, I started taking prednisone 40mg for 1 week.
    Then started tapering down 35mg for 4 days, 30 mg for 3 days week 2.
    Week 3 25mg for 4 days, 20mg for 3 days.

    I am now half way through week 4 and started at 15mg planning to take it for 4 days then 10 for 3 days, but after day 1 of taking 15mg I began having the worst headaches I have ever had in my life, combined with psycotic very angry feelings related to my pain and my head and thoughts were like controlled by devils that I could not silence. My heart rate was resting about 120+bpm and my eyes were throbbing. I could not sleep and was in a tormenting madness for 2 entire days and nights. I started taking up to 3 extra strength tylenol at a time, max 6 per day but that only took off about 5% maybe of my psycotic pain and torment. I was also drenched, absolutely drenched in sweat though that may be from all the tylenol which does that to me.

    The advice seems too varied on prednisone but some say the faster you get off it the better to avoid the long term side effects so I wanted to force myself to keep going, but the pain was beyond unbearable so I decided after 2 days of unbelievable sleepless torment to go back to 20mg. Within about 5 hours I was able to sleep and a bit of the headache calmed down.

    I am terrified of the long term side effects of prednisone and I only took it now after waiting 5 entire years trying everything else and this was a last resort. Now I am thinking my side effects are related to adrenal withdrawl and am afraid I have to taper at like 1-2mg per week or month for MONTHS more before I can get off this devil drug. But I know taking it more than about a month at most puts me into the danger area for the long term side effects.

    I am wondering is there some kind of hard core pain killer I could take to mask the pain and psycotic madness where I could force myself to continue the taper by 5mg at least per week so I don’t have to remain on this stuff for months more?

    I have read people saying that even when they do very slow tapers of like 1-2 mg per month or something that EVEN THEN when they get down to 5mg or so they STILL have all the normal tormenting side effects, so if EITHER WAY I have to go through the side effects I would rather force myself to get off it sooner rather than later, especially because I have only been on the stuff for 3.5 weeks.

    Do you think I could experiment going totally off it every other day at this point since I am still under 1 month usage and see what happens, or do you think that may be too dangerous and I may end up in a coma?

    Many questions I hope you can help with them I don’t know what to do, I am stuck feeling like a slave to this with no where to go for safety.

    Thank you

  11. Hi Dr. Pullen,
    I first started prednisolone 30mg per day for 5 days and stopped for hives. After 10 days I suffered from withdrawal symptoms and my doctor prescribed another 30mg per day for 5 days. I planned to taper it by 30mg for 2 days, 40mg for 2 days, 20mg for 2 days. Would that be alright?

  12. Carol: This is far too complex an issue to attempt to give advice in this forum, except to tell you to coordinate this therapy with your son’s physician. Good luck. DrP.

  13. Dr. Pullen, my son with lupus, was given 40 mgs of prednisone/day due to a lupus flare. He has been on 40 mgs with a 4 day hospitalization with IV prednisone at Hopkins in Baltimore. He’s now home after a total of 9 days with this dose. For two days, I lowered it to 30 mgs / day and he’s improving: lower BP, lower fever, now under 101 degrees. His weight is too low, because of GI pain from antibiotics IV. Could I keep him on 30 mgs for a few more days, then lower to 20 mgs for 3 days, then taper to 10? What do you suggest for the last dose, before he stops taking it? If you suggest a maintenance dose for lupus SLE, then how low could he go? His flare was due to stress and a doctor error of putting him on Humira for Psoriatic Arthritis, causing a lupus flare. Thanks.
    Kal

  14. I was prescribed a Medrol pack of 4 mg for sinus infection. I began having terrible anxiety, insomnia and twitching after completing the second day of treatment. So instead of taking the recommended dosage of 4 pills on the third day I only took 2 1/2. Can I now simply stop or do I need to continue tapering? And if I need to taper, at what dosages?

  15. Brian: Your situation is fairly complicated, and I am not in a position to help much. I can say that having been on very high doses of prednisone for 6 weeks does necessitate a taper to avoid potential serious adrenal insufficiency. The skipping of days with high doses is often done to allow stimulation of the adrenals to function on the off times, and possibly reduce the likelihood of adrenal suppression. The course of taper sounds a bit rapid at the end, i.e. the low dose part. You need to get in to your physician to discuss your concerns. Good luck. DrP.

  16. Dr. Pullen,

    I have lost confidence in my Dr. and her approach to my prednisone taper and I would just like your opinion. I am being treated for ITP. For about six weeks I was taking 100mg daily. Although my platelet numbers hadn’t really shown significant improvement, my doctor started me on a taper. To date, my dosage has remained at 100mg with the taper consisting of skipping days. For the first few weeks I skipped every other day (T = Take, S = Skip, T S T S T S…). Then for 2 weeks I skipped two days (T S S T S S T S S T…) Then for 2 weeks I skipped 3 days (T S S S T S S S T S S S…).

    Yesterday, at my recurring two week appointment, the PA informed me she had never heard of such a taper method and wanted to switch me. Well that didn’t sit well with me and she left to talk with other PAs about my situation as she couldn’t contact the doctor. She then instructed me to skip 2 days reducing the dosage by 20mg every third cycle. I left thinking ok, but then said this just doesn’t seem right because I had been skipping 3 days. (T80 S S T80 S S T80 S S T60 S S T60 S S …)

    Today I tried calling the doctor but was only able to talk with her nurse. Now I am on a totally new schedule. Now there are no skip days and it looks like a switch to a totally different taper method. So my new schedule starting tomorrow with no skip days is 80 80 80 60 60 60 40 40 40 20 20 20 10 10 10 done! At least there is an end date in site.

    My problem is that I feel I was not taking very much medication at all with the 3 skip days and now I am going to take a bunch of medication only to ramp down in the next two weeks. So, is this something I should worry about? Are there any red flags that jump out? Or does it sound like good medical practice?

    By the way, my platelet numbers are now reading near the lower range of normal.

    Thanks for any opinion you can give!

  17. Lynn, There is no set answer for your question. Typically PMR takes a long course of prednisone, up to years sometimes. You just need to work closely with your provider, and ideally should see someone who has at least a modest experience with PMR. I often rely on a rheumatologist for help, as PMR is not common enough for many primary care providers, including myself, to gain enough experience. DrP.

  18. Dr. Pullen – My signicant other was recently diagnosed with PMR (polymyalgia rheumatica). How slowly should the taper be? There have been some setbacks but hate to see him on high doses of Prednisone for any longer than necessary. He started at 60 mg for 5 days and was able to sucessfully taper by 10 mg every 5 days until we got to 30 mg – now he’s having the pain again. We like his provider, a nurse practictioner, who diagnosed him but would like to hear your thoughts. He is only 55 years old. Thanks! Lynn RN

  19. Alan: Topical nasal corticosteroids are usually used, along the line of the Pulmicort you mention, though that is usually an inhaled pulmonary delivery system. Discuss the options with your doctor. Good luck. DrP.

  20. Hi,

    Stumbled on this site, wonderful resource.

    Okay, male 30 years, had nasal polyps until removal in January. Was very sensitive to nasal spray, anxiety and panic attacks. Right now doing a nasal wash with Pulmicort, twice a day, morning an night. This is after the surgery. Feel fine, no anxiety.

    Saw my doctor this week, he looked in my nose, no poyps! I cannot smell, so it worries him, perhaps inflammation. He has prescribed me 50mg for 10 days and 25mg for 5 days.

    Reading quite of info of this drug and it is scaring me and I really do not want to take it. Because od the withdraw symptoms. And of course panic attack and insomnia.

    There really isn’t a question. I am scared, and keep thinking are there alternative sources to reduce inflammation in my nose.

  21. Phillippe: The taper you discuss is not an unusual taper schedule. As to safety for your individual circumstance you’ll need to discuss with your own physician. DrP.

  22. Dr. Pullen,

    I have been taking Prednisone 60mg per day for 10 days. I have been taking it for inflammation in my retina that was causing loss of vision in my left eye. My Neurologist told me today that I should taper to 50mg for 3 days, then 40mg for 3 days, then 30mg for 3 days, then 20mg for 3 days, then 10mg for 3 days, then stop.

    Is this a safe tapering schedule? I looked all over the internet for hours and cannot get an answer specific to my dosage.

    Thanks

  23. Alex: I cannot give individual advice on this blog, but anyone who has been on high dose prednisone like you have for 6 weeks needs to coordinate their taper with their physician, not just stop suddenly. Adrenal crisis could happen if you stop suddenly, a potentially very serious problem. DrP.

  24. I have been on prednisone for about 6 weeks. I started at about 60mg then after a week was admitted for iv steroids then weaned down to 80 mg and have been on a somewhat slow taper since. I have been taking 15mg for the several days and would just like to stop. My heart rate is high with any sort of activity (up to 160 bpm) just to fold laundry or go to the bathroom. My sats are good. But I feel like I am working so hard to do anything and I get so tired. I would like to just stop the prednisone now so all these side effects will stop.

  25. Jamie: You do need to discuss the taper with your physician. The symptoms you describe may be from adrenal insufficiency, and your taper may be too fast. Your treating physician should be able to help, and if not either your FP or an endocrinologist may be helpful. Good luck. DrP.

  26. Hi Dr. Pullen,

    I am on prednisone for tx of oral lichen planus associated with oral Squamous Cell Carcinoma of the R Buccal Mucosa. The cancer was treated but the lichen planus remained to the point my dr. wanted it treated as it is considered by some to be premalignant. I was on 40mg x 4 days; 30mg x 4days; etc down to the lowest effective dose. This was very hard to do because lag time to see tx effects didn’t match up to the dosage time frame. Anyway, I’ve been trying to wean off after being on prednisone for 4 months. The effective dose is too high I gather to live with the side effects (recurrent throat infections). For weaning, after I reached 5mg, I started dropping by 1mg each week. I would feel withdrawal (some mild breathing issues and extreme fatigue for 3-4 days) before I would regulate at the next level. I am now dropping from 3mg (7 days) to 2mg this week and my body is really hating it. I have extreme fatigue and mild breathing issues as before -but more pronounced. My doctor is very noncommittal in saying that maybe I should try a little longer on each dose. Perhaps. I just don’t know when I am getting into trouble and this hasn’t been made clear to me. I tried my GP and she says she didn’t write the script. So, I find myself in a predicament and don’t know if I should make an appt with an endocrinologist. Should I just suck it up and bear out the withdrawal even when it seems extreme. It seems like such low doses -but the side effects are definitely dose dependent and are seemingly much worse at this 3mg to 2mg level. Thanks for any help. I just want off of this stuff and it seems nobody has my back.

  27. Dr. Pullen,

    I have been on Prednisone for years (6 exactly) and Imuran, diagnosed with vasculitis and Behcet’s disease. I have had serious side effects, like osteonecrosis and trying to get rid of it, but can’t really. I have now again erythema nodosum on my legs. Anyway, I have tried lately some natural supplements like turmeric and now pantothenic acid. DO you think they really work something? And what do you think, how much of pantothenic acid should I take to procduce natural cortisone in my system? How long should I wazit to get any effects with B5? Thank you very much.

Leave a reply