Glucocorticoid Potency and Initial Dosing Recommendations
For initial treatment, prednisone should be administered at 0.75 mg/kg/day, while deflazacort should be given at 0.9 mg/kg/day as standard first-line glucocorticoid therapy. 1
Standard Initial Dosing by Condition
The potency and initial dosage of glucocorticoids vary significantly based on the underlying condition being treated:
Duchenne Muscular Dystrophy
- Prednisone: 0.75 mg/kg/day
- Deflazacort: 0.9 mg/kg/day
- Consider deflazacort as first-line when pre-existing weight and/or behavioral issues are present 1
Rheumatic Immune-Related Adverse Events
- Arthritis: Median 20 mg/day prednisone equivalent
- Sicca syndrome: Median 40 mg/day prednisone equivalent
- Vasculitis: Median initial 60 mg/day prednisone equivalent
- Sarcoidosis: Median initial 55 mg/day prednisone equivalent
- Scleroderma: Initial 1 mg/kg/day prednisone equivalent 1
Vasculitis
- Initial high-dose: 1 mg/kg/day of prednisone/prednisolone
- Maintain this dose for 1 month
- Do not reduce below 15 mg/day for first 3 months
- Taper to maintenance dose of 10 mg/day or less during remission 1
Lupus Nephritis
- Lower starting doses (≤0.5 mg/kg/day) may be as efficacious as higher doses
- Intravenous methylprednisolone pulse (500-2500 mg total dose)
- Oral prednisone starting at 0.3-0.5 mg/kg/day
- Reduce to ≤7.5 mg/day by 3-6 months 1
Multiple Sclerosis (Acute Exacerbations)
- 200 mg prednisolone daily for one week
- Followed by 80 mg every other day for 1 month 2
Dosing Considerations and Adjustments
Minimum Effective Dose
- The minimum effective dose of prednisone that shows some benefit is approximately 0.3 mg/kg/day 1
- For non-ambulatory patients, 0.3-0.6 mg/kg/day range is often sufficient 1
Dose Capping for Long-Term Use
- For growing children, increase dose until approximately 40 kg in weight
- Maximum cap: prednisone 30-40 mg/day or deflazacort 36-39 mg/day 1
Dose Tapering
- After favorable response, decrease initial dose in small decrements at appropriate intervals
- Reach lowest dosage that maintains adequate clinical response 2
- For maintenance therapy in lupus nephritis, target ≤7.5 mg/day by 3-6 months 1
Alternative Dosing Regimens
When daily dosing causes unmanageable side effects, consider these alternatives:
Alternate Day Dosing:
- Prednisone: 0.75-1.25 mg/kg every other day
- Deflazacort: 2 mg/kg every other day
- Less effective but may have fewer side effects 1
High-Dose Weekend:
- Prednisone: 5 mg/kg given each Friday and Saturday
- Consider when weight gain and behavioral issues are problematic 1
Intermittent Dosing:
- Prednisone: 0.75 mg/kg for 10 days alternating with 10-20 days off
- Deflazacort: 0.6 mg/kg on days 1-20 with remainder of month off
- Least effective but possibly best tolerated regimen 1
Cardiovascular Risk Considerations
Recent evidence shows dose-dependent cardiovascular risk:
- Doses ≤4 mg/day: No increased risk of cardiovascular events
- Doses 5-9 mg/day: 56% increased risk (aHR 1.56)
- Doses ≥10 mg/day: 91% increased risk (aHR 1.91) 3
Side Effect Management
When side effects become unmanageable:
- Reduce daily dosage by 25-33% and reassess in 1 month
- If still problematic, consider additional 25% reduction
- If weight gain/behavior are main issues, consider switching to deflazacort or high-dose weekend regimen
- As last resort before abandoning treatment, consider intermittent schedule 1
Special Considerations
- Glucocorticoid-induced osteoporosis: Significant bone loss occurs with daily prednisone doses as low as 5 mg; consider bisphosphonate prophylaxis 4
- Pregnancy: Glucocorticoids during pregnancy have no additional risk for mother and child 1
- Surgery: All patients on glucocorticoid therapy for longer than 1 month who undergo surgery need perioperative management with adequate glucocorticoid replacement 1
Remember that constant monitoring is needed for glucocorticoid dosing, and adjustments should be made based on clinical status, disease remissions or exacerbations, and individual drug responsiveness 2.