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. Darius: No guarantees in medicine at all. I think of the immunosuppressant effects of corticosteroids as resolving pretty quickly after stopping the meds, but really have not seen data to support that opinion. DrP.

  2. is there guaranteed immune depression some time after using burst doses of prednisone (less than 7 days)? or is it relative to each individual? how might someone mitigate any possible immune depression from burst dose prednisone?

  3. Had 2 sinus surgeries for chronic inflamation/recurring nasal polyps due to allergies/asthma. Chief complaint, unable to smell/taste foods…..depressing. When using a predisone burst, 40mg/5 days, 20mg/5days, 10 mg/10days, 5mg/20days, smell/taste senses working great. As soon as I stop taking prednisone, I lose smell/taste sense…depressing again. What is the optimal time between pred. bursting? 2,3,4 weeks?

  4. I was on 15 mg of prednisone for 3 months for ankylosing spondylitis. My rheumatologist decreased it to 10 mg because my eyes were swelling. I have been on the 10 mg for 3 months. When my doctor refilled my last prescription, he did 5 mg tablets with instructions to take 1 or 2 tablets every day. I am confused…is it ok to take it this way? He did not tell me how to determine the dosage each day.

  5. Anne: Good questions. Every person is different I suspect. I know of no real data to answer this question. I do know a crisis can be provoked by major stress like surgery, infection, etc. Obviously don’t stop cold turkey. DrP.

  6. After long term prednisone use of about 20 mg per day for two years, I am wondering how long it would take to go into adrenal crisis if the drug is stopped cold turkey. (Not planning to do this obviously…but curious). In a case of
    Colitis where an immune suppressant is taken like azathioprine along with prednisone…does that help shorten a taper of prednisone without an adrenal crisis?

  7. I was taking prednisone at 80mg for 7 days and then 60 mg for 5 days for idiopathic thrombocytopenic purpura (ITP). Are these doses high/long enough to require a taper?

  8. Anthony: Tapering of prednisone can be for two reasons. To avoid flare up in the problem being treated, and to avoid adrenal insufficicency. 11 days should not lead to adrenal insufficiency, but some problems require longer Rx. You need to discuss this with your physician. DrP.

  9. I did prednisolone for 11 days. 80 60 100 120 150 100 80 40 30 30 20 .I woke today and had no pain.After reading your web page I stopped. At 1 oclock both sides started hurting bad and I felt dizzy.I took 10mgs and within an hour both problems went away.It scared me.I guess I have to taper down now?

  10. Finishing up a dose-pak of 10mg for chronic inflammation in R shoulder, radiates to front ab. Have trouble w/inflammation in other places, moves around, but stays awhile when it does. OK to take steroid for this? MG? Long-term? I am 58 and this is a way of life-pain-that is.
    Had 4 shots in back, works good for awhile, but returns. Feel so much better when taking them-which is not often-maybe 1X 2yr. Pain is Debilitating. Life is not good. Live in small town so help is lacking, but dr. is cooperative. Suggestions?

  11. Bert: By taking the whole dose in the AM after food you achieve 2 things. First the food reduces the chance of upset stomach and ulcers. Second the body naturally produces the most cortisol in the morning so it mimics the natural diurnal cycle of corticosteroid production and we think reduces adrenal suppression less than multiple daily doses. DrP.

  12. DrP,

    LOL! i was about to confront my Dr about this. ok fine, but am sure there must a good reason for the evening intake, as my Dr recommends taking it after breakfast.

  13. i am at the beginning of a six week course of prednisone for management of a crohn’s flare. two weeks at 40mg/day, then taper. i take it in the morning when i get up, and i think they have given me more energy than i have ever had in my life. but i have been seemingly “crashing” at around 8pm, when i would prefer to be functional for a couple more hours.

    do you think i can space out my dosing for morning and afternoon to prevent my energy loss and dizziness? or is it more likely unrelated? (or unsafe!?)

  14. thanks for the reply Dr. it is a relief to hear that i should be taking 20 instead of 60mg for my situation. i must discuss with my dr this big difference then before i start. would you have any links, site, or anything to support the 20mg for my case? thanks again.

  15. Bert: It’s suboptimal to take prednisone in the evening, but if you are on a short course it’s probably OK. You should ask your physician for your particular circumstances. Prednisone is often prescribed at 20 mg doses in situations like yours. DrP.

  16. hi Dr.

    am starting with 60mg a day. available package is 5mg. meaning i have to take 12 tablets once a day. is it ok to take 30mg(6 tabs) in the morning, another 30mg at night?

    thanks.

  17. Lori CS: Some rheumatologist use burst courses of prednisone for RA flares, but if you have these very often you need to discuss the use of disease modifying therapy with your doctor, as prednisone is not generally felt to alter the joint damage or ongoing problems in RA. DrP.

  18. Let’s asy “a person” was prescribed a medrol dose pack – 6 days starting at 24mg and tapering to 4mg. If he forgot to take 2 pills so he only took 16mg ont he first day– then took 24 on the second day could he go down to 20 then 16 then 8 then quit (none left)? Would he get the same therapeutic effect?

  19. Dr. Pullen:

    Thank you for this information. I look forward to discussing whether short burst therapy will be beneficial for my RA flares. I usually refuse to take prednisone due to the side effects I experience, but think this option may allow me to control my flares without having the nasty temper and headaches I get from it. I’m fortunate to have a Rheumatologist who encourages me to learn as much as I can about my disease and treatments, then once we discuss allows me to make informed decisions about my own treatment.

  20. Bert: These are specific questions for your physician. Without knowing your specific details these are questions I cannot try to answer. Usually the NSAIDs are OK to take with prednisone. DrP.

  21. hi,

    i’d like to seek advice on some concerns. do i stop any physical exercises while on 2wk treatment? also can i continue taking anti-inflammatory supplements w/c i’ve been taking for a couple of months already?

    thanks.

  22. Dr Pullen,
    i quote you, “I would not necessarily taper after a 2 week course of prednisone unless there was a reason to taper to prevent flare of the underlying condition in most cases.”

    this is comforting for me since i will be taking 60mg for exactly 2 weeks coinciding with my radiotherapy treatment for my graves’ ophthalmology. i was very worried when no tapering was given by my Physician. Thank you very much for your blog.

  23. Hank: I know of no real data to help answer your question. Prednisone 10 mg is enough to lead to adrenal suppression if used for long periods. I would not be concerned about using a 7-10 day course several times a year if there was a good indication. Obviously you and your doctor will need to decide how often is enough to put you at risk. DrP.

  24. Dr. Pullen,

    have recurrent dermititis, 64, excellent health. saw derm and allergest. on low dose 10 day prednisone. question: if dermititis returns lets say in three months can low dose prednisone be used safely again. or better question, is how many times and how much apart can low dowse short duration prednisone be used without much worry , thanks

  25. D. Marion: I am not in a position to try to comment on your husband’s scenerio. Your doctor is in a much better position to discuss this with you than I am. DrP.

  26. Hello Dr. Pullen,
    would taking an 8mg shot of decadron and then 30 mg of prednisone the same day and then 20 mg the next day then about 10 mg the 3rd and then stopping abruptly would that cause problems with the adrenal gland and possibly protein in the urine? My husband had terrible side effects and now they are saying something may be obstructing his kidneys because he had protein in his urine and hyaline casts (usually related to someone with dehydration). Now his physician says he should have probably started the prednisone the day AFTER the decadron shot. Your thoughts?

  27. Thank you Dr. Pullen for the highly informative information on Prednisone. It helped set my mind at ease where my doctor didn’t have the time to explain further.

  28. Blake: I simply cannot give individual medical advice on this blog. I am saying that I often do not taper prednisone after just a 2 week burst course. You need to discuss your situation with your own physician. DrP.

  29. Dr. Pullen,

    I am sorry for the misunderstanding. So am I correct in understanding there would be no need to taper with prednisone under two weeks? Just stopping without a taper under 2 weeks is ok?

    Thanks in advance.

  30. Blake: I would not necessarily taper after a 2 week course of prednisone unless there was a reason to taper to prevent flare of the underlying condition in most cases. DrP.

  31. Dr. Pullen,

    I hope I did not phrase the question incorrectly. I am simply seeking thoughts on anything I should do, if anything to assist in the restart up of my adrenals, and if 60mgs is considered a high dose, and only being on under 2 weeks would it significantly decrease my chances of them restarting. Most emergency room docs state 7 days on 60mgs then quitting cold turkey should not effect them. PMP seem to go by the theory the taper down is the way to go. One can’t help but get confused by this. Thanks in advance.

  32. Dr. Pullen,

    Had an allergic reaction to antibiotic on January 28th. Did prednisone 60mg for 5 days, 50 for 2 days, 40mg for 2 days, 30mg for 1 day, and 10 mg the last day. Total of 11 days. On day 11 the last dose I had a little shakes accompanied with anxiety in the am for 1 hour, then next hour a state of great wellness, then the next hour back to normal the rest of the day. I needed to quit due to the extreme facial flushing that came in the late afternoon from what I beleive was the prednisone flash effect. Since I was on somewhat higher dosages and tapered faster, would my adrenals be totally shut down since under 2 weeks, also how fast should the adrenals start to recover. I am a healthy male and athletic. Please enlighten me a little. I have never taken pred before and hope not to again. Thanks

  33. I had pneumonia in early December in hospital- given medrol in hospital, then tapered dosing starting with 60 mg q d x 3, 40 x 3, 30 x 3 etc. At 20 mg of taper started experiencing extreme anxiety and panic attacks. Increased dose for several days on advice of physician. Then decreased per physician. Had another episode of pnemonia in January. Started on 40 mg prednisone. 3 days later had extreme anxiety and panic attacks. MD ordered to D/C prednisone. Now 9 days later still having anxiety and panic attacks. Started on Xanax and Buspar. I have no psych hx. How long will these reactions continue?

  34. I was treated in the hospital with medrol for pneumonia in December and was on the 60 mg x 3 days, 40 for 3, etc. I started experiencing severe anxiety and panic attacks while on about 20 mg..One doctor increased my dosage saying the taper was to fast, one week later another doctor pulled me quickly, saying that I was having sides effects not withdrawal. I then had a recurrent pneumonia and was placed back on prednisone even after the doctor knew the above, I was taken off three days later when I started having panic attacks and great anxiety. I have been off the prednisone for one week and still have panic attacks and anxiety. Put on xanax and buspar. I do not have a psych hx. How long will these side effects???? last.

  35. A doctor I recently saw gave me Prednisone 40mg a day for 3 days. I am afraid to take it because I had a systemic reaction to a Medrol-dose pack last November and had to stop it. I have had an upper respiratory / sinusitis infection of some sort since Thanksgiving – I’ve tried antibiotics but don’t do well on them at all. I don’t know whether to try the Prednisone 40mg a day, or would 20mg a day for 3 days be sufficient? It has been over one week now and am hesitant to contact the doctor.

  36. I am scheduled for mastectomy surgery in 9 days. However I have post nasal drip drainage from allergies or a cold that has irritated my lungs and asthma and has required use of my rescue inhaler several times a day. Typically when my asthma is inflammed like this, my pulmunologist gives me a short burst of prednisone – but am I too close to my surgery date to take this now? How long does it stay in your system?

  37. Hi and thanks for the article. I have seen recently a couple of scripts for prednisone 60mg daily for 5 days only. I wondered about tapering, as it has been more common to see scripts with doses tapered rather than just stopping. So, there should be no worries at this dose for 5 days then stopping??

  38. Hap: With less than about 2 weeks of high dose corticosteroid therapy there is not usually any significant adrenal suppression. After a 3 day course the adrenals should function normally immediately. The body usually makes about 20 mg of cortisol daily, the equivalent of about 5 mg of prednisone, though every individual is different. DrP.

  39. So, you think 60 40 20 is ok? and then stop . how long until the adrenals turn back on after the three days? how long is prednisone in the body? what amount does the body make on its own ? sorry for the questions ,I am worried
    thank you

  40. Hap: I don’t think any physicians would recommend a taper unless the disorder being treated required one. DrP.

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