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.

272 Responses to Prednisone Taper

  1. Dr Pullen

    After my last post i stopped the medicine Other than extreme bloatness which was there even earlier had no other side effect at least till now will keep everyone posted

  2. Akshat: I cannot give individual advice in this forum. You should consult the urgent care doctor who gave you the Rx. In general no taper is needed after a brief course of prednisone. DrP.

  3. Dr. Pullen

    I was discovered with a herniated L5 S1. I was going for a surgery but i met this Doctor who is from an Urgent care he gave me a shot of cortisol and told me to take a course of Perdnisone. he advised me 60mgX5days 40mgX2days and 20mgX2 days.
    I started my course day before yesterday. Took my first tablet and i had a piercing pain in my left side of abdomn and constipation. Next day i took some citrucel then yesterday i took the 60 mg dose again… felt bloated and couldnt sleep… as if something was stuck in my stomach (took both doses while having food).

    Now i am not willing to carry on this… is it possible that i can stop from today…or should i taper off…please advise.

  4. I have taken short doses 3-4 x a year since having 2 back surgeries. It removes the inflammation like clock work. Normally a 7 day dose, no taper, 20mg 2xday. I am having seasonal allergies and sinus problems, saw an “acute” doctor today (not my regular), she put me on a 12 day taper pack. On day 1, can say the power dose of 40Mg has stopped the pain in my face fast. Do this for a few more days then taper. Two different problems, two different dosing methods. Good luck everyone, I will likely not sleep much tonight, but my headache is gone, face is looking normal and I can breathe!

  5. Jill S.: Generally speaking no taper is needed for a 1 week course, although often for contact dermatitis I use a somewhat longer course as flares are common with a week long treatment course in poison ivy. DrP.

  6. my son was prescribed 8o mg. for 7 days for poison ivy (second time in a month) with no taper. i am used to a taper when my kids have poison ivy or asthma. the poison ivy is finally gone….no taper is ok?

  7. Hi,

    I have allergic rhinitis and the best treatment for me is 10 Days of predinisone (I will try this time 60mg for 7 days and stop),
    I never experienced but some difficulty in sleeping as a side effect.
    In fact i feel more energetic as a good effect.

    now my question is how often can repeat this 7-10 days treatment?
    is it safe to repeat it each 3 month?

    in my case my allergy goes away for 2 month after the treatment.
    (and my sense of smell goes back too)

    Thank you for your reply.
    Farid

  8. Robin: Your situation is complicated enough that advice in this forum is not appropriate. You need to discuss your taper with your physician. DrP.

  9. I had been ill for 6 months, seeing the doctor every two weeks. I was put on 5 short bursts…the typical 60 3 days,40 days, etc.
    I still got worse. I ended up in ER and was referred to a Pulmonary doctor who i will see on august 9. I had been on 60 mg for 3 weeks. I am tapering now….30mg. I read on tapering down from this high amount by cutting it in half. I am just not certain how many day i need to take the “half dose” amounts. I am feeling so much better and it’s nice to be breathing! I am a diabetic,controlled. This dose has been a testing nightmare and I have to take more insulin to keep control. I was just hoping for so advice on the half dose taper. I am on day 3 of 30 mg and still feeling fine.
    Any help is appreciated.

  10. Ash: These are questions for your doctor. As a general rule for a 12 day course of prednisone no taper is needed. Usually the safest way to take prednisone is to take the whole daily dose with a meal in the AM.

  11. Also this is being taken by 10mg pills. I space them through out the day because I wasn’t given instructions on how to take them. I’m already on day 5. Is this ok?

  12. I’ve been put on 12 days of Prednisone. 3 days at 40mg, 3 days at 30mg, 3 days at 20mg, and 3 days at 10mg.
    Is this a slow enough taper and should it cause any problems to my health?
    Thanks.

  13. Mitch: I am not aware of any documented cases of adrenal insufficiency related to inhaled or nasal corticosteroids. The brief treatment of a Medrol dosepak should not lead to adrenal suppression either. DrP.

  14. Dr. I’ve been taking Pulmicort flexhaler 180 mcg 2 puffs 2x a day(720 mcg)for many years. I also take Nasonex 2x a day. I seem to have symptoms of Adrenal suppression, including easily dehydrated, weakness, tiredness, dizziness. Could Pulmicort/ Nasonex be causing these symptoms?

    Also, how long does it take for adrenal glands to return to normal after a 6 day Medrol pack? ~thanks

  15. Melba: Adrenal fatigue is a poorly defined condition. I doubt that a Medrol dosepak will do harm. Cortef is hydrocortisone, used for adrenal insufficiency. As to natural ways to reduce inflammation lots of things proposed but few if any proven. DrP.

  16. I have adrenal fatigue. I recently injured my knee and was put on Medrol dose pack 4mg (21) for 6 days. Will this medication hurt my adrenals? Any side effects that may come my way? Is there another natural way to help with inflamation? I have heard of Cortef, but not sure what it is or how it works? Thank you.

  17. Whether the prednisone will help the effusion is a question I cannot try to answer, too many variables. No taper is needed for a 4 day course of prednisone. DrP.

  18. I sustained a soft tissue injury of my knee 8 weeks ago and recent (one week ago)MRI reveals a large joint effusion and moderate arthritis but no torn cartilage/ligament. I have continued swelling and discomfort and naprosyn/ice/compression have not helped much. The PA for the orthopedic group has ordered prednisone 60 mg x 4 days and I am reluctant to begin for fear of bad side effects as I am used to tapering doses. Would you expect prednisone to help with the joint effusion? The orthopedic doctors are reluctant to do an aspiration.

  19. Vee: I have no way to tell what is causing your skin symptoms. You need to consult your primary physician about this. It’s not likely from the prednisone. DrP.

  20. Dr Pullen,
    I had an allergic reaction on Tuesday June 5 (to what we are unsure) that landed me in the ER. The reaction consisted of hives, shaking or tremors throughout my body, and swelling of my lips and face. At the ER I was given Prednisone 60mg along with Ranitidine and Benadryl. I was told to take 60mg of Prednisone for the following 5 days, and to see my PCP by Friday. Symptoms subsided somewhat at the ER and I was sent home and told to return if they came back. On Thursday morning the symptoms returned and I wound up back in the ER. The symptoms returned one more time late Thursday night. After visiting my PCP on Friday(still with some swelling of my lips and face) I was told to begin tapering off the Prednisone on Monday. I lowered the dose to 40 mg for 2 days, 30 mg for 2 days, 20 mg for 2 days, and 10 mg for 2 days. In total I was on Prednisone for 14 days. I have been off Prednisone for 6 days, and am now experiencing skin issues. Breakouts on my face, red bumpy rash on my arms and shoulders. I do not typically experience these issues. Is this a result of being on the Prednisone, and if so, how long should it take to resolve? Thanks in advance, Vee

  21. Hi Dr. Pullen. I read your article with great interest and am hopeful that you can shed some light on a complex situation.

    My friend has Crohn’s disease and has been on and off prednisone (mostly on) for the past 18 years. Her highest dose was 60mg/day for about two years, but that was a very long time ago. Over the years, she has suffered with many of the problematic side effects from prednisone, and in fact had been warned by several doctors to avoid it if at all possible, but various symptoms have necessitated that she take it anyway. For the past several years her dose was about 20mg/day, and then a bit lower. In the past couple of years, she developed significant Cushing’s symptoms. She tapered off of it over several months, and has been completely off for about six weeks.

    Since the taper hit about 10mg/day, she has been in severe pain, head to toe, and has been feeling extreme fatigue (not to mention SOB, skin problems, depression and irritability, and other problems). This has all gone from bad to worse as she has been off of it completely. Despite knowing that she would feel worlds better if she restarted it, she has been committed to staying off the prednisone because of all of the problems it has caused and the risks to her future.

    I have two major questions: 1) Does it make sense that the pain and fatigue are still so severe after being off it for a few weeks, considering her slow taper?

    2) As she anticipated from her history, she has been having episodes of severe constipation, abdominal cramping, and pain. In the past, when she has had particularly bad episodes, she has used the prednisone at higher doses to reduce the intestinal inflammation and help get things moving. She is afraid to do that at this point because she does not want anything to jeopardize the process of restarting the adrenal gland functioning. If she were to take a few doses, perhaps 30mg for three days, would she in fact be restarting the clock, or would her body pick up where it left off in terms of working toward making its own cortisol? And, if she were to do it, would she need to taper?

    I should mention that I recognize that these are complicated issues. She unfortunately does not have a doctor to consult with about this right now. She moved recently and is having trouble finding a physician knowledgeable about her illness, and does not trust that the doctors in an emergency room would consider all of the complex issues before just giving her prednisone.

    Any guidance you could provide would be greatly appreciated. She’s truly suffering. Thank you!

  22. I need some suggestion. I have ITP, and it´s my first time with steroids. The doctor gave me 3 weeks of 60mg, but I started tapering off after the 2nd week. Reason for this? My first week, my platelet count rose from 47 to 116, but the second week it got down to 57. On my 5th week of steroid, I got my menstruation so my platelet count went from 57 to 32. (by the way, the count didn´t rose from 57 cuz I was tapering off so it maintained its count). After my menstruation, I got anemic, and my count went from 30 to 39 and now 30. This is my 6th week and I´m taking 6mg.
    My question is: Is it OK to rise the dose to about 30 or 40mg for 4 days and start tapering by 5 or 10 mg every 2 days in my 6th or 7th week of steroid? Any sugestions?

  23. Hello Dr. Pullen. I was given 5 days of 2 0 mg prednison/day. Can I stop after this days the treatment immediatly? (Sorry for my bad english)

  24. Dr. Pullen I was recently put on a Medrol dose pack for allergies. I took my last pill this morning. I have been in bed for 2 days with extreme fatigue, headache, body aches, chills, sweats. Could this be a withdrawal from the Medrol?

  25. Sarah: We usually recommend the whole dose of prednisone in the morning with breakfast to minimize the adrenal suppression effect, though sometimes multiple daily doses are used for better 24-hour drug activity. You need to ask your physician about this. DrP.

  26. Dr. Pullen, I am taking 5 mg/twice daily, now on week three. (Severe joint pain, waiting for blood work to come through from my reum)I am having terrible insomnia which I am guessing is from Prednisone. Do you recommend a time of day to take these meds? Can I take both pills in the morning to minimize insomnia? Would I need to taper off of this dosage? Thank you-

  27. I developed a slight rash and facial puffiness after my first encounter with CT scan dye. When I went to the ER that night, they gave me 40mg of prednisone for four days.

    Now I’m afraid to stop after the fourth day because I don’t feel like the rash and puffiness fully diseappeared even with the prednisone and benadryl on my second day. What should I do?

  28. Gale: Using the other meds is fine. I don’t know about the oral surgery. Both the prednisone and the asthma flare up may be factors, you need to discuss this with your surgeon. DrP.

  29. Hi, I have been in the middle of an asthma flare triggered by a virus (not my first time). The doctor prescribed a 50mg/5day of prednisone with no taper and that seemed odd to me until I read the above. He also prescribed a 5 day zpack antibiotic. I have two questions:

    Is it okay to continue with the other (symptom-treating) meds I had been taking for the congestion and runny nose (mucinex and zyrtec, etc) or the fever reducers?

    I was scheduled for an oral surgery (pulling a tooth and placing imbutment for a dental implant) tomorrow afternoon. I was wondering if you think I will have to reschedule that…I have no other opportunity so I am prepared to beg.
    THANK YOU

  30. Jennifer: Insomnia is an occasional side effect of prednisone, but is not likely from “withdrawal”, rather just form the med itself. It should go away soon, nothing is usually needed to help. DrP.

  31. Dr. Pullen,

    I had 1 50 mg. dose of prednisone for a bad skin rash (later estimated to be from Scombroid fish poisoning). I developed full body hives one and a half hour after taking the prednisone, so I discontinued it and did not “taper.” The next day was fine. Tonight, the second day after, I have insomnia. Can it be from the prednisone? Will it linger? Is there anything I should do except wait it out?

  32. I got an allergic reaction to a lip balm causing my lips to swell and causing a rash around my mouth. Then a saw a rash on my arms. My doctor prescribed 40 mg of prednisone for 3 days, 30 mg for 3 days, 20 mg for 3 days and 1 mg for 3 days. Can a apply a cream on ointement on the rash while taking the prednisone?

  33. Liz: I can’t give specific advice in situations like this. Still I’d expect the symptoms to resolve soon, and don’t think your symptoms are adrenal insufficiency, rather prednisone side effects. DrP.

  34. I self-medicated with Prednisone for poison ivy because I’ve had it prescribed so many, many times. I took 80mg/day for two weeks and stopped abruptly when rash cleared. Withdrawal symptoms of severe depression, edginess and sleeplessness lasting 7 days now. Do I need to resume a small dose and taper, or can I expect my adrenal glands to catch up?

  35. Liz: My post is focused on there not being a need to taper to avoid adrenal insufficiency. Whether to taper to avoid flare in a condition like your rash is another issue altogether. It would be safe to use the 50 mg for another 2-3 days, but a three day taper is OK. DrP.

  36. I got an allergic reaction causing a bright red rash and swelling running down the left side of my face. My doctor prescribed 50 mg of prednisone for four days. Originally he said I could stop on day five, no taper. It’s day four and swelling is gone, but since the rash has only slightly faded he said I should continue a few more days, to 30, 20, 10. Based on your post, I can’t see any benefit to this taper. Wouldn’t I be better off at a couple more days of 50, or none at all? thanks

  37. Dr. Pullen, I usually taper the prednisone treatment for 8 days for migraine headaches when nothing else works. After the first 60 mg dose, the migraine will usually go away. Is it safe to stop after the first or second 60 mg dose? Thank You!

  38. Thanks Dr Pullen for your information. I am 72 very active runner recently diagnosed with microscopic colitis. My GI put me on a 3 week course of prednisone 30mg to 20mg to 10mg weekly.

    This looks close but not identical to your burst treatment. How does that weekly tapering sound to you? After finishing the second week of 20mg and going to the 10 mg dosage I did start to feel sore and fatigued. But it only lasted about three to four days at 10mg and now that I’m at the end of the course I feel fine. Don’t know yet if the colitis issue is really solved.

    Meanwhile during this period and for the last two months I was taking 5mcg of cytomel because my endo thought my T3 was low. I wonder if that had any impact on my course of prednisone?

    In general, what do you think of the tapering 3 week treatment of prednisone? Not exactly the same as you were describing but close.

    Thanks for any comments. Randy

  39. Darius: The higher the dose the more likely side effects like high blood sugar, psychosis etc, but as long as a course is brief adrenal insufficiency on stopping is not expected. The dose you mention is well withing a typical dosing range. DrP.

  40. yeah that makes sense, best to err on the side of caution.
    would the amount of prednisone taken during the burst effect its duration? i see so many varying dosage amounts on the web that it’s more than a little confusing, (i’m more interested in using it to reduce inflammation after an IBD type “flare”)
    is there a daily top end range, and can that same amount be continued for the duration of the burst? example, 20mg 3x/day for ten days

  41. Darius: Good question. I consider a burst less than 2 weeks really. There is no data that I have seen to tell how long between burst courses of prednisone is needed to avoid adrenal suppression. My opinion is that it is best to avoid more than a few, maybe 6-8 burst a year. DrP.

  42. thanks for the earlier reply – 1 more question: if “bursts” are 7 days or less, and keeping it in this time frame negates the need for tapering, how much time between bursts is necessary to offset any potentially negative sides?

  43. Rah: This type of Rx, for a total of 40 days is not what I’d consider “burst” therapy, but a moderately quick tapering course. Anyway, I’d be reluctant to use that type of course more than every few months. Again little data to guide an opinion though that I know about. DrP.

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