Glucocorticoid tapering on chronic prednisone plus upadacitinib
For patients who have taken systemic glucocorticoids for more than 4 weeks and no longer need them, tapering to a daily physiologic equivalent dose is recommended, followed by a slower discontinuation regimen [1]. Chronic high-dose therapy requires a prolonged taper because hypothalamic-pituitary-adrenal (HPA) axis recovery can take up to 1 year or longer [2].
Physiologic dose targets for taper completion
Prednisone physiologic equivalent dosing is listed as prednisolone 3 mg to 5 mg (or hydrocortisone 15 mg to 25 mg) [1]. HPA-axis recovery is described as possible once the glucocorticoid dose is tapered to a near-physiologic level such as 4 mg to 6 mg prednisone [2].
Prednisone taper schedule example (50 mg/day for >1 year)
The following schedule is a practical example consistent with gradual dose reductions until reaching a physiologic-equivalent prednisone dose, then step-down dosing through discontinuation [1], [3].
Stepwise prednisone reductions (from 50 mg/day)
- Week 0–1: 50 mg daily → 45 mg daily [3]
- Week 1–2: 45 mg daily → 40 mg daily [3]
- Week 2–3: 40 mg daily → 35 mg daily [3]
- Week 3–4: 35 mg daily → 30 mg daily [3]
- Week 4–5: 30 mg daily → 25 mg daily [3]
- Week 5–6: 25 mg daily → 20 mg daily [3]
- Week 6–7: 20 mg daily → 17.5 mg daily [3]
- Week 7–8: 17.5 mg daily → 15 mg daily [3]
- Week 8–9: 15 mg daily → 12.5 mg daily [3]
- Week 9–10: 12.5 mg daily → 10 mg daily [3]
- Week 10–11: 10 mg daily → 7.5 mg daily [3]
- Week 11–12: 7.5 mg daily → 5 mg daily [3]
- Week 12–13: 5 mg daily → 4 mg daily [3]
Discontinuation phase once near-physiologic dose is reached
After reaching a daily physiologic equivalent dose (prednisone equivalent to prednisolone 3 mg to 5 mg), stopping is recommended using the regimen below [1].
- Start: 4 mg prednisone daily as the daily physiologic equivalent dose [1], [2]
- Days/Weeks 14–15: 4 mg prednisone every other day for 2 weeks [1]
- Days/Weeks 16–17: 4 mg prednisone twice a week for 2 weeks [1]
- After Day/Week 17: stop glucocorticoid [1]
Clinical monitoring during tapering
Signs and symptoms of adrenal insufficiency should be monitored during tapering below physiologic-equivalent dosing [1]. If signs or symptoms of adrenal insufficiency develop on doses below physiologic-equivalent levels, the physiologic-equivalent dose should be managed by prescribing double the physiologic-equivalent dose daily until symptoms resolve, then reducing back to daily physiologic-equivalent dosing for 1 week, then using a slower tapering regimen [1].
Key decision points affecting taper speed
A slower taper is recommended when the glucocorticoid dose is approaching physiologic levels because smaller decrements are required as the total daily dose nears the physiologic range [2]. For patients on long-term therapy, tapering should only be attempted when the underlying disease is controlled and glucocorticoids are no longer required [2].
Stress-dose precautions during and after taper
Patients with current or recent glucocorticoid use who did not undergo biochemical testing should receive stress-dose coverage when exposed to stress [2].
Medication-specific considerations with upadacitinib (Rinvoq)
Glucocorticoid tapering during treatment with upadacitinib should follow standard-of-care disease control criteria because concomitant corticosteroids can be reduced and/or discontinued in accordance with standard practice [4].