Tapering steroids after flare

[rosalinda]

I need some advice. After successfully reducing very gradually (more gradually than recommended by rheumy) I had a flare up which didn't settle and I increased pred from 1mg back to 10 mg. I then went to 9mg after a week, with no problems. I'm worried that I increased too much after reading advice on your site. I'Ve been on 9mg for 3 weeks. will I now have to decrease very slowly ? I' m fed up that I didn't get your advice before acting as I had forgotten the sweats and nightmares induced by steroids and was just relieved tobe out of pain!

[Celtic PMRGCAuk volunteer]

Rosalinda, provided your flare has now settled on the increased dose, you should find that you are able to reduce back down to the dose at which you last felt comfortable fairly quickly.

When I had a flare at 3mgs, my rheumy increased me to 10mg for 2 weeks, then 7.5mgs for 2 weeks, then alternate days of 7.5 and 5mgs for 2 weeks, then 5mg.

It sounds as though you reduced successfully as far as 2mg before the flare at 1mg, so perhaps you could now try reducing to 7.5 for 2 weeks, followed by alternating 7.5 and 5 for 2 weeks, then 5 for two weeks. You could then try slipping in the odd day at 4mgs to 'test the water'. But you will need to taper much more slowly and in smaller decrements at these very low doses, remembering that the lower you get on the steroids, the higher the percentage drop.

We have a few tried and tested methods of reducing below 5mgs if you find yourself starting to struggle again.

[PMRpro Ambassador]

The most likely reason for the flare was that you dropped too quickly to the 1mg - and because of that you don't REALLY know what dose you were fine at do you? So dropping fast too far might miss the ideal point.

It is better to use a moderately high dose to really stamp out the inflammation quickly but many doctors feel adding 5mg is enough. However, you are where you are. If you use a slow reduction pattern you can stop at any time if you notice any stiffness or pain returning and mark time for a week or two and see if it goes away. In your position, If you are confident you were perfectly OK at 5mg before, then I would try a week alternating 7.5mg and 9, a week of 7.5, a week alternating 7.5 and 5. Then go about the next stage slowly! If the underlying autoimmune disorder is being active again then you may not get to 2 or 3 mg and be as good as you were before which is the main reason I say go slowly.

[rosalinda in reply to PMRpro]

thanks for the prompt replies. As you say, I'm not really sure at what level I was OK. I will follow your advice and see what happens. It is so good to know that you there for advice

[PMRpro Ambassador in reply to rosalinda]

I got into a major flare because the form of corticosteroid I was switched to apparently didn't work for me! At 20mg Medrol I was a mess, at 15mg of a form of prednisone the next day I was so much better. Before the duff tablets I had been fine at 9mg, but never less, but my GP encouraged me to really take my time getting down to 10mg and this time I made it to 4mg over a period of about 18 months. I tried 3mg and was OK for about a month and then I got an achey bicep. I went back to 4mg which just about worked, I used 5mg for about a week and went back to 4mg. Ache gone, job done.

But below 5mg - which MrsO was told to rest at for a few months by her outstanding rheumy - stick at each dose for at least a couple of months before even thinking about the next step. Half mg drops are worth thinking about - you need to identify that "lowest dose that manages the symptoms" as accurately as you can. For example, 4.5mg may be enough, 4mg not, but 4.5mg is 10% less than 5! For simplicity you can alternate one day 4 and one day 5.