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.
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.