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.

283 Responses to Prednisone Taper

  1. does a three day corse of prednisone cause any lonterm problems . I was prescibed day 1,60 day 2,40 day 3,20 . do I need to taper at a more lower doseage.?
    thank you

  2. DQ: A more constructive comment/question might be to ask a more specific question or for clarification, rather that trying to stereotype physicians or just give a rant. DrP.

  3. Typical of medical doctors…they give directions, but can’t explain how their “medicines” are supposed to work. Dr. Pullen probably isn’t even a doctor at all….well- maybe self-proclaimed.

  4. Sheri: Unfortunately the burst course is not likely to last long if you really have RA. I don’t think a 6 day course of prednisone puts many people at risk for adrenal insufficiency. Signs of adrenal crisis are very nonspecific and can be symptoms of shock, like low BP, rapid Heart rate, etc. Good luck. DrP.

  5. I am so happy I have found this post. I was recently prescribed prednisone for suspected RA (though there’s a 4-month wait to see the rheumatologist.) I started three days of 40mgs and the past 4 days at 20mgs, and I don’t want to take it anymore. I feel better, though I’m aware the pain and inflammation may come back, I’m willing to tough it out for four more months until the doctor can put me on something less … sketchy. I am concerned about my adrenal glands though. I am a skydiver and all around adrenalin junkie. Should I give myself a little break before I return to my activities? Are there symptoms I should be aware of?

  6. Daniel: I am not aware of any solid evidence on this topic. You need to work this issue out with your doctor, weighing the risks and benefits. DrP.

  7. Suzanne: It can be still the prednisone and it should resolve soon if the prednisone is the cause. DrP.

  8. dr. i was placed on 16 day tapering of prednisone for reaction to a bug bite that went systemic with cellulitis and joint pain,, one week after finishing the dosing I still have 5 lbs of extra water weight,hands swelling .still craving carbs, mild headache, and constipation. Can these symptoms be attributed to the prednisone and my response or is it my imagination. If its the prednisone ,how long till my body returns to normal?

  9. How often can a “Burst” of say 60 mgm x 5 days be repeated? is there a time interval or waiting period in between bursts?

  10. Thank you for your reply. Is My dosage a high end dosage to begin with? As I said, I don’t have much experience with prednisone. Much obliged for your help.

  11. Liz: Most experts agree that there is no need to taper burst courses of prednisone less than 2 weeks duration unless the taper is needed as a part of the treatment. Adrenal suppression should not be a concern. DrP.

  12. I am going on a 10 day course of prednisone for inflammation due to coughing. Does this sound like a safe taper? ( the following are all milligrams) 35 35 30 25 20 15 10 10 5 5.

    I have taken the medro pak once before ( 6 days).

    Am nervous about the dosing above. Is it a high dose? I have no previous experience with prednisone. Thank you.

  13. Austin: There is not a one-answer-fits-all for your question. It will require you to work with your doctor to monitor you as you continue to taper, but likely longer than you wish. DrP.

  14. I have been on varying doses of prednisone for 14+ months because of drug-induced autoimmune hepatitis. After a bad flare last year, I spent 3 months on 60mg. Since then, I have spent the last 6 months tapering down to 10mg, the lowest dose I have ever been on. I have about every mental and physical side effect possible. I want off this stuff now. With the length of time I have been on pred, how long will it take me to taper off the last 10mg? Or could I consider switching to hydrocortisone, etc.?

  15. I’ve had three “short” rounds of prednisone after a severe allergic reaction to allopurnol. I shed three times even with the prednisone, and every taper (my docs chose to do that even with the short rounds) I got rashes that were not AS bad as the reaction, but where too uncomfortable to face without some help. I’m on my fourth short round of prednisone for that reason, and though the itching and rash aren’t quite as bad, I’m fascinated by how many different types of rashes and pricklies I’m still having. I can live with these ones, but I’ll be off the prednisone in four more days and I’m afraid it’ll happen again. Is there a ballpark “duration” for this “rebound rashing” to stop? I REALLY don’t want to be on this stuff forever! And is there anything I should do to try to keep from having to take it again? I have some palliative creams and ointments, but I want off ALL of it!

  16. Judy: I know of no studies to tell us how often a person can get a burst course of high dose corticosteroids. I also am not a big fan of the medrol dosepak as short courses of a fixed dose of prednisone are equally safe and no taper is needed for a 6 day course, but I’d be reluctant to prescribe more than a few courses a year if other options are available. DrP.

  17. I was given the Medrol 6 day dosepak for sinusitis last week. All of my sinusitis symptoms are gone. I was reluctant to take a steroid but my Dr. convinced me that short term use would not cause significant side effects. My question is, how often can one use the 6 day dosepak safely, without causing the significant side effects of steroid usage?

  18. Kevin: Most experts would not consider a 2 week course of prednisone 40 mg long enough to need a taper. DrP.

  19. Hello, I’ve been put on prednisone for two weeks (14 day supply) for treatment of granulation tissue on my ear drum from a tube. The ENT was able to clear most of the granulation tissue, but he wanted to remove the tube in case of granulation tissue on the other side of the tube. I wanted to keep the tube in because I’m flying in about a month. So he gave an alternative of the prednisone therapy. I wasn’t given a taper, just 2 tablets daily for two weeks. I think it’s 40mg, but it might be just 20mg. Should I be on a taper for this? I am concerned with possible withdraw symptoms of this medication..

  20. Jon: There is no specific one-regimen-fits-all taper schedule that I am aware of, so each patient needs to work this out with their physician. I tend to go very quickly in tapers from 2=4 week courses of even high dose prednisone. If I need to have someone onhttp://drpullen.com/wp-admin/edit-comments.php?comment_status=moderated#comments-form more than about 10 mg daily for more than about 4 weeks I tend to go much slower. I think this is fairly common practice. The old practice of tapering even short courses does not seem to be necessary or advantageous. DrP.

  21. Just looking for some relevant literature I’ve not been able to locate. Found the Marshall protocol but hard to see if it’s truly evidence based.
    In patients with a longer than 2week prednisone administration what’s a typical tapering schedule once the optimal administration of the initial dose has passed?
    Any suggestions on where to look?
    The condition requires 2-8 weeks of management at the starting dose of 40mg daily.
    Thanks!
    Jon

  22. Crystal: I agree with your doctor and pharmacist that no taper is usually needed for a course less than 2 weeks. Taper was the standard years ago, now most experts agree no taper is needed for relatively short courses of Rx. DrP.

  23. I was given an 8 day dose of Predinsone for poison ivy. I was told to take 2 a day everyday of the 8 days. The pills are 20mg each. My sister n law is an RN and she said usually if the dose is over 3 days the person should be tapered off. I called my doctor and my pharmacist and they seem to think an 8 day is fine to just quit cold turkey. I don’t want to do something I shouldn’t so I was wondering what your advice would be for this.

  24. Megan: Sorry to hear about your struggles with asthma with your children. It can be really difficult. I cannot try to give individual medical advice in this forum. You should discuss the duration of treatment with your physician. DrP.

  25. Hi dr.p

    My 5 yr old daughter is on high dose of prenisone for 30 days for bronchial spasm/ asthma. Is that a long time for a kid to be prednisone or not? Also do you reccomend anything food or supplement wise that helps the body deal with the steroid easier? Im a new mom with two little ones with terrible asthma… Seems like iam starting to get presribed a awful lot of prednisone lately…. Thanks again!!

  26. Hill: I am not in a position to give specific advice as to whether to follow your physician’s advice or not in this forum. In general the skipped days though unusual is not unsafe or illogical, just for brief courses the skipping of days like tapering of prednisone is not likely to be necessary to avoid adrenal suppression. Maybe there is something else in your daughter’s case I’m not aware of so I cannot give specific advice. You should discuss the safety, need to take the prednisone or not, and concerns about side effects with your child’s doctor as they are familiar with her situation and can give you personal advice. I cannot do that in this forum. DrP.

  27. Dr Pullen, my daughter has been given a short term course of Prednisone for a heavy cough that has not cleared after a 3 day 500mg dose of Azithromycin and 3x a day 2mg of Albuterol in pill form.

    This therapy is complete, but since it didn’t clear, her pediatrician perscribed 15 pills of 20mg Prednisone. She is supposed to take 3 at once per day totalling 60mg a day as 3x20mg pills once a day for three days, stop for a day, then take another 3x20mg for 60mg in pills all at once for this 5th day, stop again on day 6 and the final day 7, the last 3x20mg pills at once for the last day. SO, a total of 15 pills over the course of 7 days with 3 days straight, and alternately 2 days skipped. Does this sound right dosage wise?

    Also, do I need to worry about side effects? She is 15 years old, 5’3″ and 113lbs. Thanks for your help. I am on the fence giving it to her after reading side effects and having the 7 day dose pack when she was an infant and I suffered an anaphlytic shock where my lips blew up. I felt very depressed taking the medrol dose pack, so this is why I am leery if she should take it aside from all the other side effects I’ve read about.

    Thank you for your earliest reply!

  28. This is not a simple question, and certainly not one I can give online advice about. A longer course of prednisone will likely improve pulmonary function, but may adversely impact muscle strength. This is one to discuss with your doctor. DrP.

  29. I had been given a 5 day course of pred. (40, 30, 20, 10 and 5) for my lungs (after having a lung x-ray and PFT test). I am training for a marathon and got some help from this treatment. My doctor was being conservative because she didn’t wan’t to hurt my training. I have now been given another course of pred. to take care of the lingering symptoms I still have but I am wondering if this will weaken my fitness. The marathon is in 2 and a half weeks and I don’t want to start the drug now if the side effects will be worse during the run. I do have a lofty goal and feel I could gut it out and then start the last treatment or start the treatment just before the race. Any suggestions

  30. Rhonda: Your daughter has a very difficult condition and I all I can suggest is working with her physicians to try to find the best of the less than optimal options. Best of wishes. DrP.

  31. My daughter is 26 years old and was diagnosed with SLE and Sjogrens at age 15. She has been on 60 mg of Prednisone for almost 2 years from a severe lupus attack several months after the birth of her daughter, who was born with neonatal lupus. She has tried to taper off and can only get down to 20 mg before she has a flare and has to increase back up. She has kidney and bladder damage, pancreatitus with suedo cyst, anemia, skin deteriation rash and sores, bone and tooth loss, swelling of face, hands and feet, a hump on the base of her neck. Not to mention muscle atrophy. She has been hospitalized twice with the first stay for 2 months, the second stay for 2 1/2 months and will need to go back after the psuedo cyst matures for a major surgery. I think a lot of the issues she is having is due to the long term Prednisone use. How can i get her off this horible medication for good? Any advice would be very appreciated. Her rhuematologist just keep bumping her up and down and can’t offer any alternatives due to the pancreatitus. Thanks in advance.

  32. i have been to visit my doctor as I had a heavy cold (affecting my head, ears, sinuses & chest)& a chesty cough. I have asthma but apart from my brown (preventor) inhaler, I haven’t taken my blue ventolin reliever inhaler for years.
    She has prescribed me very short of prednisolone (30mg for 3 days) to try and ensure things don’t worsen before i travel on holiday next week. however reading the side effects & weaning stuff online has put me off taking them.
    Will 30mg have much of an effect if only taken for 3 days?

  33. Melanie: Unfortunately your persons with no medical background may be right. Delayed hypersensitivity dermatitis from poison ivy often require a 2-3 week course of prednisone to prevent recurrence.

  34. Dr. Pullen,
    I was prescribed prednesone for poison ivy and have taken 60 mg for 3 days and 40 for two days. I would like to stop using it. The poison ivy seems to be drying up. I do not like taking any medications whatsoever even an occasional advil. I was warned ( by persons with no medical background) that if I stop taking it then the poison ivy will come back. Is this true. I am a 50 yr old female in great health taking no meds. Thanks, Melanie

  35. Brigit E: At 2 weeks on 60 mg if I had not been on prednisone for a long time prior I’d feel comfortable stopping cold turkey regards adrenal suppression. It is a borderline issue though and you should discuss with your doctor.

  36. Dr. P., I have AIED 25+ years now. Totally deaf in right ear w/tinnitus. Began having similar hearing loss in LEFT year in my 20’s (I’m 47) with “attacks” to my ear arising every 5 years or so. Have been on Prednisone 3-4 times over the past 25 years, and it worked to reverse “attack” and restore my hearing the first 2 times. Third time (4 years ago?), no response and was left with about a 40% hearing loss and terrible tinnitus (which I successfully treat with Xanax XR, of all things). About 2 weeks ago, started to get a sudden sublte decline in hearing with slight increase in tinnitus “sounds”. About 10 days after onset, when it didn’t reside, started on 60 mg of Prednisone and am at day 7 now on that dose. Per Rx, I am to start tapering (again, only been on 7 days), but have had no change in hearing or tinnitus. I realize you can not give specific medical advice, but if it were YOU in this case, would YOU choose to continue the 60 mg for, let’s say, another week to see if it works? And if so, when when YOU discontinue? Also, if you DID decide to continue for another week, would you taper or stop cold turkey? It would be a total of 2 weeks at 60 mg a day at that point. Thanks so much!

  37. Asthana p.r You need to coordinate this carefully with your doctor. This post is about short term courses of prednisone therapy. Long term courses require careful tapers and monitoring. Good luck. DrP.

  38. i was diagnosed for temporal arteritis and started with 60 mg prednisone daily.after a month this has now been reduced to 50 mg per day.i understand that this tapering will continue for almost a year and will have to take the med for almost 2 years.how should the taapering go now?viz reduce by 10 mg every week or every two weeks or in any other manner?

  39. Mark, You need to consult your own doctor re this Your case is far too complex to consider answerimg here, Good luck, it appears you have had a tough go of it. DrP.

  40. I have been on prednisone, in varying dosages, for 15+ years,prescribed for a series of illnesses that began in 1995 with a bout of meningitis, then acute sinusitus persisting for many years and through 3 sinus surgeries; in the meantime i developed adult onset asthma; recurring bouts of pneumonia requiring ER and/or hospitalization. Last year I was hospitalized again with meningitis complicated by acute kidney damage. Two months ago I was diagnosed with sjogrens syndrome to which many of the aforementioned ailments are now attributed. To top it off I have severe degenerative arthritis affecting my lower spine with stenosis and bulging disks causing intensely painful sciatica flare ups. Prior to the sjogrens diagnosis prenisone bursts were always prescribed with long tapering periods, always with the objective of getting to 0, but always failing when another flareup of one thing or another would trigger the cycle all over. The rheumatologist has put me on Plaquenil and reduced my pred dosage to 5 per day which he says will be necessary for life. That has held for two months, until three days ago when I started a burst at 60 for an especially painful sciatica flare. My question is, can I take 60 for 7 days then drop back down to 5, or should I taper back down?

  41. Thanks for the information. I will bring it up with my doctor. Unfortunately he will be out of the office until the 12th, which means it will be another week of 20 mg until I see him and he can agree to cut me off entirely. I wonder if three weeks of pred is too much to cut off at once? I am on it for a weird case of ABPA (allergic type aspergillosis)- no chronic disease.

  42. I cannot give specific advice on this blog, but generally if a patient has taken 40 mg daily for 2 weeks only, not a different dose prior, they can safely stop prednisone without a taper putting them at risk for adrenal insufficiency. Whether to taper to prevent recurrence of the problem being treated is another issue altogether.

  43. Am I to understand that if someone has taken 40 mg for exactly 2 weeks, they are still within range (less than two weeks) to be able to stop “cold turkey” – or is a quick taper necessary?

  44. David: For specific medical questions you need to consult your health care provider, DrPullen.com is intended as a source of health care information, but not as a source of individual health care advice. Hope you do well with your RA and your upcoming surgery. DrP.

  45. Dr pullen, I have RA I started on Actemera June 7 andwill receive my next injection july 7. My question is my new doctor perscribed 20 mg of predisone for 2 wk, 15 for 2 wk 10 for 2 wk then 5 . this day 10. I tapered off after 3 days to 15 3 days 12.5 for 3 days, day eleven I was going to do 10 for 3 days then 5. the reason is I have atear in my rotator cuff may need surgery. seeing the doctor on monday.
    can I stop alltogether or taper. I also take hydrocodone for pain.I also take 6cc/ml of methotrexate. please advise.
    David

  46. I cannot respond to individuals with personal health advice on this blog, but this question raises great questions that I can reply to in a general sense. Long term use of prednisone, such as discussed by Elena above, is far different than the short term use discussed in this post. Long term use as she describes is far different, and a physician supervised slow taper is essential. Stopping suddenly is very dangerous, and not at all acceptable. With long term use this can precipitate an adrenal crisis, and a slow supervised taper is needed. The issues in Elena’s case are likely to be twofold. First avoiding adrenal insufficiency from long term adrenal suppression. Second control of the RA without the prednisone. It’s a very difficult situation, and careful supervision by her physician is essential. This is not something she or anyone in a similar situation should even consider doing without physician supervision.

  47. Dear Dr. Pullen,
    I am writing to you in desperation. I’ve had rheumatoid arthritis since 1976. Since then I’ve been on Prednisone almost constantly. I tried other treatments but I remained on Prednisone to keep up with a demanding work life. Enbrel was wonderful for a while, but after a very serious infection I was taken off and had to rely on Prednisone again. I tried to take less when I realized the horrible side effects. For the last few years I was on 20 mg a day most of the time but, during flare ups I increased that to 60 mg, then followed with taper down to my “normal” dose (20mg). I am now suffering the consequences of the prolonged use. My bones are in horrible shape. I recently had a spine implant that is not staying in place due to the condition of the bones and I’m healing very slowly. During the surgery they increased the dose and I’ve followed with a taper. Every time I go down, swelling returns and I am plagued with extreme fatigue. I am at 15mg/day. Am I addicted? What can I do? Are my adrenal glands permanently disabled? Who can help me go to 0? Is it best to go to 0 rapidly? Where can I research prolonged use of Prednisone? Please respond, please help me!

  48. MAXIDEX DEXAMETHASONE WARNING

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