What is the recommended dosing regimen for prednisone (corticosteroid) in managing a flare?

From the Guidelines

For managing a flare, prednisone is typically started at 40-60 mg daily as a single morning dose, followed by a gradual taper over 7-14 days, as this dosing regimen has been shown to effectively control disease in most patients with adult onset Still's disease (AOSD) 1. The taper schedule often reduces the dose by 5-10 mg every 1-2 days, depending on symptom severity and patient response.

• Key considerations for prednisone use in AOSD include:
  • Initial dose: 40-60 mg daily for most flares, with higher doses of 60-80 mg for severe flares and lower doses of 20-40 mg for milder flares.
  • Tapering: gradual reduction over 7-14 days to minimize side effects and prevent adrenal crisis.
  • Administration: taking prednisone with food can help minimize gastrointestinal side effects, and morning dosing aligns with the body's natural cortisol rhythm.
  • Monitoring: patients should be closely monitored for side effects, including increased appetite, fluid retention, mood changes, and elevated blood glucose, especially those with diabetes.
  • Duration: longer courses of prednisone (beyond 2-3 weeks) require more gradual tapering to prevent withdrawal symptoms. It is essential to note that the use of prednisone in AOSD is often necessary, as most patients will require steroid treatment at some point in their disease course, with responses ranging from 76% to 95% 1.
• Additional treatment options, such as methotrexate (MTX) and tumor necrosis factor (TNF) inhibitors, may be considered for patients who do not respond to prednisone or require prolonged steroid use, as these agents have shown modest success in controlling disease and reducing steroid requirements 1.

From the FDA Drug Label

The initial dosage of prednisone may vary from 5 mg to 60 mg per day, depending on the specific disease entity being treated. In situations of less severity lower doses will generally suffice, while in selected patients higher initial doses may be required. If after long-term therapy the drug is to be stopped, it recommended that it be withdrawn gradually rather than abruptly In the treatment of acute exacerbations of multiple sclerosis daily doses of 200 mg of prednisolone for a week followed by 80 mg every other day for 1 month have been shown to be effective. (Dosage range is the same for prednisone and prednisolone.)

The recommended dosing regimen for prednisone in managing a flare is to start with a dose between 5 mg to 60 mg per day, depending on the disease entity being treated. The dosage should be individualized and adjusted based on the patient's response. In cases of acute exacerbations, such as in multiple sclerosis, a dose of 200 mg per day for a week, followed by 80 mg every other day for a month, has been shown to be effective 2. It is also important to note that when stopping long-term therapy, prednisone should be withdrawn gradually rather than abruptly 2.

• The dosage requirements are variable and must be individualized based on the disease under treatment and the response of the patient.
• Constant monitoring is needed in regard to drug dosage.
• Alternate day therapy may be considered for patients who have been on daily corticoids for long periods of time, but it may be difficult to establish and not always successful 2.

From the Research

Prescribing Prednisone for a Flare

To manage a flare, the recommended dosing regimen for prednisone (corticosteroid) varies depending on the condition being treated. Here are some general guidelines based on available evidence:

• For rheumatoid arthritis (RA), low doses of prednisone (not exceeding 10 mg/day) are safe and effective in suppressing inflammation 3. The dose can be given in daily divided doses (5 mg BID).
• For polymyalgia rheumatica (PMR), a regimen of 15 mg/day for 3 days, 10 mg/day for 7 days, and 5 mg/day for 1 year, followed by tapering at 1 mg/day/month, may be effective 4.
• For episodic cluster headaches, oral prednisone (100 mg for 5 days, followed by tapering of 20 mg every 3 days) can be used as a short-term preventive therapy 5.
• For antihistamine-resistant chronic urticaria, a short course of oral prednisone (starting with 25 mg/day for 3 days) can induce remission in nearly 50% of patients 6.
• For systemic lupus erythematosus (SLE) patients with clinically quiescent disease, maintenance of 5 mg/day prednisone can prevent flares 7.

Dosing Considerations

When prescribing prednisone for a flare, consider the following:

• Start with a low dose and taper slowly to minimize side effects.
• Use the lowest effective dose to control symptoms.
• Monitor patients for potential side effects, such as osteoporosis, and take preventative measures (e.g., supplemental calcium and vitamin D) 3.
• Adjust the dose based on the patient's response and condition being treated.

Tapering Prednisone

When tapering prednisone, consider the following:

• Taper slowly using 1 mg decrements every couple of weeks to a month 3.
• Monitor patients for signs of relapse or flare.
• Adjust the tapering schedule based on the patient's response and condition being treated.