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How to Taper Prednisone – Prevent Side Effects & Withdrawal

How to Taper Prednisone – Prevent Side Effects & Withdrawal

In this article, I explain who needs to taper prednisone and why tapering prednisone is necessary. Next I explain the scientific foundation of tapering. Finally, I conclude with some examples of prednisone tapers for different situations. Four videos give explanations for each of these topics as well.

It is important to understand that tapering is a slow process taking at least several weeks if not several months. There are different methods depending on your situation.

Like Flying an Airplane

It’s like you’re the pilot in an airplane. Normally you let your cortisol system, or stress coping ability, run on autopilot. But when you took prednisone, you stopped the autopilot function and decided to pilot it yourself. The autopilot normally works flawlessly without any help from you. And with prednisone you aren’t a very good pilot! When you stop taking prednisone, now your airplane of cortisol needs to learn how to run on autopilot again. It takes a while for the autopilot to wake up and start working again. It’s not a switch you can just flip on; more like a slowwwww warm-up.

Who needs to taper?

  • Anyone taking more than 20 mg prednisone per day for 21 days or more.
  • Anyone with Cushing side effects like Moon Face and belly fat.
  • If you are taking prednisone at bedtime.

The reason for these prednisone patients needing a taper is because these three are indications that your body has not been running your cortisol system. Read more in the next section.

It’s less likely that people in these situations need a long taper:

  • Less than 21 days of prednisone.
  • Using prednisone every other day at 10 mg or below.

Why Taper?

Prednisone must be tapered for several reasons.

First, no one wants to continue taking prednisone because it has so many side effects.

“Adverse effects associated with prolonged corticosteroid use, even in relatively low doses, are substantial, and the side effects associated with long-term use of moderate doses are unacceptable. Indeed, corticosteroid-associated morbidity is viewed by patients as the single greatest impediment to good quality of life.” (Reference 1)

Second, it cannot simply be stopped “cold turkey” because the adrenal system needs time to recover.

According to the second scientific article, “…Neither the total dose, the highest dose of prednisone, nor the duration of therapy was the significant predictor of HPA axis recovery.” This means that the dose and how long you take prednisone might be related but are not a perfect predictor for whether or not you need to taper prednisone.

Why Taper Slowly?

Prednisone is blocking your body making cortisol. Because you take prednisone, your body is likely incapable of making cortisol on its own. In scientific terms, your hypothalamic-pituitary-adrenal (HPA) axis has been hijacked by prednisone and is not doing its job anymore. It needs time to recover.

The second scientific article, below, sums up the reason to taper slowly better than I could:

“Slow tapering of glucocorticoid serves 3 purposes:

  1. To prevent reactivation of the patient’s underlying disease,
  2. To prevent withdrawal syndrome and
  3. To give the adrenal glands more time to recover.

“There are no controlled clinical trials of methods for safe withdrawal from glucocorticoids. A systematic review about glucocorticoid withdrawal in chronic medical disorders, did not find sufficient evidence to recommend any particular withdrawal regimen. …a gap in clinical research and therefore current withdrawal schedules do not insure that a patient will not develop adrenal insufficiency.

“We recommend that if the patient no longer needs glucocorticoid treatment for the underlying disease, the most rational withdrawal strategy is to exchange the respective glucocorticoid to the physiological hydrocortisone, which is then tapered. This might be done in cooperation with an endocrinologist. Furthermore, patients should be instructed, that if they start feeling unwell during or after the glucocorticoid tapering they should not taper the steroid dose any further, but contact the clinician responsible for the glucocorticoid tapering.”

To learn more about Prednisone Withdrawal Syndrome, check out this article I wrote: Why Prednisone Withdrawal May Be As Dangerous As the Treatment Itself.

Only One Study

The only study with a standard tapering schedule was published in the prestigious New England Journal of Medicine. In it, patients with Giant Cell Arteritis were tapered either over 26 weeks (6 months) or 52 weeks (one year).  Only 14% of the patients tapered over 26 weeks sustained remission, while 18% in the 52 week taper stayed in remission.

This study did show that it is possible to put an entire population on the same tapering regimen, but it did not show:

  1. That the tapering was effective at disease remission.
  2. That the tapering prevented withdrawal syndrome.
  3. Or that it prevented adrenal insufficiency.

Much, much more research is needed to determine the best tapering schedule for people on prednisone.

Check out this video I made about Tapering:

Why we taper Prednisone, and the consequences of going Cold Turkey:

Art not a Science

Tapering prednisone, then, is not a science, but an art. There is no scientific evidence to support one strategy over another. It’s very individualized and based upon response from the patient’s disease and their withdrawal symptoms.

Example Short-Term Taper

If you have a short-term condition that needs a “zap” from prednisone, then your doctor might start at 40 mg. Here’s a typical taper seen commonly in pharmacies:

  • 40 mg for a week
  • 30 mg for a week
  • 20 mg for a week
  • 10 mg for a week
  • 5 mg for a week
  • …and Stop.
  • Total = 5 weeks

Whether that taper works for you or not depends on many factors, and you need to stay in constant communication with your doctor if it’s not working. This is not the only taper strategy. There are many, many options, so don’t think that just because your doctor prescribed something different that it’s wrong. Let me repeat, there is no scientific strategy for tapering.

Here’s a video I made explaining the typical prednisone tapering schedule:

Example Long-Term Taper

If you have been on prednisone longer than 6 weeks, then you probably need a slower taper. You might be okay with the taper above, but maybe not. Like I said, this is very individualized.

If you’ve been on long-term, then you might need to decrease by 10-20% per week. Here’s an example from that study, above.

  • 20 mg for a week
  • 17.5 mg for a week
  • 15 mg for a week
  • 12.5 mg for a week
  • 10 mg for a week
  • 9 mg for a week
  • 8 mg for a week
  • 7 mg for a week
  • 6 mg for a week
  • 5 mg for a week
  • 4 mg for a week
  • 3 mg for a week
  • 2 mg for a week
  • 1 mg for a week
  • …and Stop
  • Total = 14 weeks
This video explains how to taper prednisone down from 15 mg:

Slower Taper

But that still might be too fast for you. Maybe you can only drop 10% per month instead of per week. So you’d follow that same milligram decrease, above, but go down only once a month.

  • 20 mg for a month
  • 17.5 mg for a month
  • 15 mg for a month
  • 12.5 mg for a month
  • 10 mg for a month
  • 9 mg for a month
  • 8 mg for a month
  • 7 mg for a month
  • 6 mg for a month
  • 5 mg for a month
  • 4 mg for a month
  • 3 mg for a month
  • 2 mg for a month
  • 1 mg for a month
  • …and Stop
  • Total = 14 months
Here’s a video I made about tapering in this slower strategy: Prednisone Taper Too Fast – Prednisone Withdrawal Side Effects

Alternate Day Strategy

Another strategy is to drop on alternating days. So instead of dropping from 10 mg for a month directly down to 9 mg for a month, you decrease every other day. For example:

  • 10 mg on Sunday
  • 9 mg on Monday
  • 10 mg on Tuesday
  • 9 mg on Wednesday
  • 10 mg on Thursday
  • 9 mg on Friday
  • 10 mg on Saturday

Then the next week you’d drop to 9 mg completely. Hold 9 mg for a few weeks. Then when dropping from 9 mg down to 8 mg, you’d drop like this:

  • 9 mg on Sunday
  • 8 mg on Monday
  • 9 mg on Tuesday
  • 8 mg on Wednesday
  • 9 mg on Thursday
  • 8 mg on Friday
  • 9 mg on Saturday

And repeat by dropping down to 8 mg completely, and holding for a few weeks. Then repeating the strategy with the next milligram decrease, and so on.

Many people find the biggest triggers are when dropping below 10 mg or below 5 mg… both being a tough hurdle. If so, try this alternate day strategy. You could even go every 3 days instead of every other day if you need it even slower that second week.

Switch to Hydrocortisone

Finally, if you have reached this point, you might need to speak to an endocrinologist, a doctor who can help you with these specific hormone issues. The endocrinologist may switch you from prednisone to hydrocortisone, a sister of prednisone. It lasts less time than prednisone and has to be taken several times per day. But it’s the drug more often used when trying to overcome prednisone-induced adrenal insufficiency, also known as secondary adrenal insufficiency.

The bottom line: you need to work closely with your doctor and listen to your body. None of these tapering strategies are perfect for everyone, so you need to work together to find what works for you.

Do not EVER stop taking prednisone suddenly without your doctor’s instructions to do so!

References:

  1. Collinson N, Tuckwell K, Habeck F et al. Development and Implementation of a Double-Blind Corticosteroid-Tapering Regimen for a Clinical Trial. Int J Rheum. 2015;589841:1-6. http://dx.doi.org/10.1155/2015/589841
  2. Dinsen S, Baslund B, Klose M et al. Why glucocorticoid withdrawal may sometimes be as dangerous as the treatment itself. Eur J Int Med. 2013;24:714-720. http://dx.doi.org/10.1016;j.ejim.2013.05.014
  3. Stone JH, Tuckwell K, Dimonaco S, et al. Trial of Tocilizumab in Giant-Cell Arteritis. N Engl J Med. 2017;377:317-328. DOI: 10.1056/NEJMoa1613849

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