'Reduce prednisolone by 5 mg every two weeks' depends on the patient tracking where they are, and it breaks the first time a flare, a holiday or an admission interrupts it. A dated schedule - 20 mg until 2 October, 15 mg until 16 October, and so on, with the review date on the same line - survives all three.
It also creates the record that the alternative lacks. Cumulative glucocorticoid exposure is the variable that drives infection, bone loss, diabetes and cataract in these patients, and it accumulates invisibly through repeated short courses and stalled tapers that nobody totals. A dated schedule in the letter means the next clinician can see what was actually taken rather than what was intended.
Give the patient the same table, and put on it the two things that make tapers fail: what to do if symptoms return - contact the team, do not simply go back up and stay there - and the sick-day rule for anyone who has been on treatment long enough to be adrenally suppressed.
- Write the taper as dated steps with the review date on the same schedule
- Give the patient a copy of the same table, not a verbal instruction
- State explicitly what to do if symptoms return, rather than leaving the dose to the patient
- Include sick-day rules for anyone on a prolonged course
- Total cumulative glucocorticoid exposure at each annual review and record it
Why it matters
Cumulative steroid dose is what causes most of the harm, and an undated taper is how it stops being measured.
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