What is the recommended dose of prednisone for a patient with infectious mononucleosis (mono) and severe pharyngitis with tonsillar hypertrophy?

Prednisone Dosing for Infectious Mononucleosis with Severe Pharyngitis and Tonsillar Hypertrophy

Prednisone at a dose of 0.5-1.0 mg/kg daily (maximum 80 mg daily) for 1-2 weeks with tapering is recommended for patients with infectious mononucleosis who have severe pharyngitis with significant tonsillar hypertrophy. 1

Indications for Corticosteroid Treatment in Mono

Corticosteroids should not be used routinely for all cases of infectious mononucleosis but should be reserved for specific complications:

• Severe pharyngitis with significant tonsillar hypertrophy
• Impending airway obstruction
• Respiratory compromise
• Severe pharyngeal edema

The evidence clearly shows that corticosteroids should not be given for common symptoms of infectious mononucleosis such as fatigue, fever, or mild pharyngitis 2.

Dosing Recommendations

For patients with severe pharyngitis and tonsillar hypertrophy due to infectious mononucleosis:

• Initial dose: Prednisone 0.5-1.0 mg/kg daily (maximum 80 mg daily) 1
• Duration: Short course of 1-2 weeks with tapering 1
• Administration: Single daily oral dose

Treatment Algorithm

1. Assess severity of tonsillar hypertrophy:

   • Degree of airway obstruction
   • Ability to swallow
   • Respiratory distress

2. For severe cases with significant tonsillar hypertrophy:

   • Start prednisone at 0.5-1.0 mg/kg daily (maximum 80 mg)
   • Monitor for clinical improvement within 24-48 hours

3. For cases with impending airway obstruction:

   • Consider hospitalization for close monitoring
   • Higher end of dosing range (1.0 mg/kg daily)
   • Consider otolaryngology consultation if no improvement

4. Tapering schedule:

   • Begin tapering after clinical improvement (typically after 3-5 days)
   • Reduce by approximately 10-20 mg every 1-2 days
   • Complete taper within 1-2 weeks

Monitoring and Follow-up

• Assess response to therapy within 24-48 hours
• Monitor for common corticosteroid side effects:
  • Hyperglycemia
  • Mood changes
  • Insomnia
  • Increased appetite 3

Important Considerations

• Corticosteroids may mask symptoms of other infections or complications
• Patients should be withdrawn from contact or collision sports for at least four weeks after symptom onset 4
• If there is minimal improvement with corticosteroids and severe tonsillar obstruction persists, acute tonsillectomy may be considered in selected cases 5

Cautions

• Corticosteroids should not be used routinely for uncomplicated infectious mononucleosis
• Benefits are small and inconsistent for general symptom relief 2
• Reserve treatment for those with significant airway compromise or severe pharyngitis that affects hydration and nutrition

Compliance Considerations

Patient compliance with high-dose oral prednisone regimens has been shown to be excellent (>94%) even when multiple tablets are required daily 6, so this should not be a barrier to appropriate dosing.

Alternative Treatments

For patients who do not respond to corticosteroids or have contraindications:

• Ensure adequate hydration
• Provide appropriate analgesics and antipyretics
• Consider ENT consultation if airway obstruction is a concern

Remember that the mainstay of care for most infectious mononucleosis cases remains symptomatic treatment without corticosteroids 4.