Steroid taper builder

How to use it

Pick the steroid and fill in the course, or click Use the clinic default for the clinic’s usual prednisone taper: 40 mg daily for 14 days, then down 5 mg every 7 days (9 weeks, 308 × 5 mg tablets). Enter the start date and answer the two Pneumocystis questions, and the schedule appears. Change any number to build a different course.

To slow a taper there are two options, and they can be combined:

• Longer steps at low doses: keep the 5 mg reductions, but from a set dose (20 mg by default) reduce every 10 or 14 days instead of every 7. From the default, every 14 days from 20 mg gives 13 weeks; every 10 days gives 75 days.
• Smaller steps at low doses: for example 1 or 2 mg at a time from 10 mg. Big steps stop at the threshold, then the smaller step takes over. Doses that are not multiples of 5 mg need 1 mg tablets.

Tick the tablet strengths the patient will get (Canada: 1 mg, 5 mg and 50 mg). The tool counts tablets per day, per step and for the whole course, and the chart note’s prescription lists how many tablets of each strength to supply. Half tablets are not used, and no 2.5 mg tablet is marketed in Canada, so 2.5 mg steps are not offered; use 1 mg tablets for steps that are not multiples of 5 mg.

For budesonide, the schedule follows the Canadian product monograph. Cortiment is 9 mg once daily for up to 8 weeks with no taper. Entocort is 9 mg for up to 8 weeks, then optionally 6 mg for up to 3 months; the monograph says to taper to stop but gives no schedule, so any 3 mg step is your choice.

Print patient schedule prints only the patient copy, in the view chosen above the schedule: a list (dated table and plain instructions) or a calendar (one month grid per month, each day showing the dose and the number of tablets, with a ruled edge where the dose changes). Calendars print on letter paper, about two months to a page.

Reading the result

Every steroid course

• Bone: calcium 800–1000 mg and vitamin D 800 IU daily while on steroids. Assess fracture risk at the start; check bone density for prolonged (over 3 months) or repeated courses (BSG 2019). BSG 2025 adds: in people over 65, estimate fracture risk and consider an oral bisphosphonate. The Osteoporosis Canada 2023 guideline excludes people needing high-dose glucocorticoids, so it does not replace this advice.
• Pneumocystis: see the next section.
• Adrenal insufficiency: about 1 in 4 people with IBD have adrenal insufficiency after systemic steroids; consider it after 4 weeks or more at 5 mg/day or more (Law 2025). ECCO 2026 advises tapering any course of 20 mg/day or more that lasted over 2 weeks.
• Side effects: about half of patients get short-term effects such as acne, edema, sleep and mood disturbance, glucose intolerance and dyspepsia. Check glucose and blood pressure.
• Stopping: after prolonged courses, taper and warn about steroid withdrawal (weakness, nausea, joint pain), which can mimic a flare.
• Timing: once daily, in the morning with food (BSG 2025).

Pneumocystis pneumonia (PJP) prophylaxis

Clinic practice, consistent with ECCO 2026 (Statement 31), which says to individualise prophylaxis by the degree of immunosuppression:

• Why not for everyone: PJP is rare in IBD (absolute risk under 0.2%; ECCO 2026 does not recommend routine prophylaxis). Prophylaxis is a daily antibiotic, and its harms, including C. difficile infection, matter more in IBD.
• Case by case: ECCO 2026 lists other risk factors: a lymphocyte count below 0.2 × 10⁹/L, cyclosporine or tacrolimus, a JAK inhibitor, older age and chronic lung disease. It also lists prolonged high-dose steroids (15 mg/day or more for over 4 weeks), which a standard 40 mg taper meets; clinic practice is that prednisone alone does not need prophylaxis.
• Methotrexate: co-trimoxazole interacts with methotrexate. ECCO 2026 advises caution, noting that low-dose methotrexate may be acceptable.
• ECCO does not define which drugs make up “triple” immunosuppression or how long to continue prophylaxis. The definition above is the clinic’s.

When to escalate

• Steroid-dependent: cannot get below prednisolone 10 mg (or budesonide 3 mg) within 3 months of starting, or relapses within 3 months of stopping.
• Steroid-refractory: active disease despite up to 1 mg/kg/day of prednisolone for 4 weeks.
• Steroid excess: two or more courses in a year.
• BSG 2025 adds: start advanced therapy if the response to oral steroids is inadequate within 2 weeks, if a taper fails, or to avoid repeated courses. Steroids are not maintenance therapy (ACG 2025).

Where guidelines differ

• Taper length. BSG 2019 and ECCO 2026 wean 40 mg over about 6–8 weeks; BSG 2025 describes 40 mg reducing by 5 mg a week (8 weeks); ACG 2025 says 8–12 weeks. In the only randomised comparison (94 steroid responders), a 6-week course was inferior to a 10-week course for steroid-free clinical remission at 6 months (Kumar 2026). This tool flags courses under 6 weeks as short and adds a note for 6 to under 8 weeks. The clinic default (two weeks at 40 mg, then down 5 mg weekly) gives 9 weeks. Slowing it to every 14 days from 20 mg gives 13 weeks, just over ECCO’s 3-month limit, so the tool adds that caution.
• Pneumocystis. BSG 2019 suggested prophylaxis above 20 mg/day only with triple immunosuppression; BSG 2025 makes no new statement; ECCO 2026 says to individualise, strongly considering it with triple immunosuppression. The tool gives the clinic’s rule, which is consistent with ECCO 2026: recommended for triple immunosuppression, otherwise usually not needed.

Pitfalls

• UK guidance is written for prednisolone; in Canada we prescribe prednisone. The doses in this tool assume they are interchangeable milligram for milligram. Check this against your local formulary.
• 2.5 mg steps are not supported: the tool uses whole tablets only, and no 2.5 mg prednisone tablet is marketed in Canada. Use 1 mg tablets (for example 2 or 3 mg steps).
• Ileal-release budesonide (Entocort) does not work for UC; Cortiment is for UC (BSG 2019).
• Stopping budesonide: BSG 2019 says that once remission is achieved, budesonide should be tapered over 1–2 weeks, and that slow tapering is not needed because it causes little or no adrenal suppression.
• For acute severe colitis, IV steroids come first. See the ASUC tool.