Tapering Oral Prednisone in Osteoarthritis Patients Awaiting Knee Replacement

Introduction to Prednisone Tapering

• The American College of Rheumatology recommends against the use of oral corticosteroids for osteoarthritis management, as prednisone has no proven efficacy for osteoarthritis pain or disease modification 2
• Patients on ≥15-20 mg/day prednisone have an increased risk of postoperative infectious complications following total joint arthroplasty, with an odds ratio of 1.68, making this a critical modifiable risk factor 1, 3, 4, 5

Tapering Protocol

• The CDC defines 20 mg/day prednisone for ≥2 weeks as the immunosuppression threshold, and optimal surgical candidates should be on <20 mg/day when possible 3, 4, 5, 1
• Reduce prednisone by 5 mg every 3-5 days to avoid adrenal insufficiency in patients who have been on ≥20 mg daily for more than 2 weeks 1

Alternative Pain Management

• The American College of Rheumatology conditionally recommends oral NSAIDs (such as celecoxib) or topical NSAIDs for osteoarthritis pain 2, 1
• Acetaminophen up to 4,000 mg/day can be used, though it is less effective than NSAIDs for moderate-to-severe pain 6, 2
• Tramadol may be considered for additional analgesia while awaiting surgery 2, 1
• Duloxetine 30-60 mg daily can be added as an alternative or adjunct to initial treatments 6

Perioperative Considerations

• If surgery occurs before complete taper is possible, patients on ≤16 mg/day should continue their usual daily dose perioperatively rather than receiving stress-dose steroids 3, 4, 5
• Corticosteroid injections should be avoided for 3 months preceding joint replacement surgery due to infection risk 6, 7

Important Considerations

• Osteoarthritis is not an indication for systemic corticosteroids, and prednisone should not be continued simply because the patient has been on it chronically 2, 1
• Even doses >15 mg/day increase infection risk significantly, and low-dose prednisone is not safe perioperatively 3, 1