Prednisone Prescribing Guidelines
Prednisone should be prescribed at specific doses based on the condition being treated, with a general recommendation of 30-60 mg daily for initial therapy of severe conditions, followed by a gradual taper to the lowest effective maintenance dose. 1, 2
Initial Dosing Considerations
- Initial dosing ranges from 5-60 mg per day depending on the specific disease entity being treated 2
- For severe conditions, two standard regimens are equally effective 1:
- Prednisone alone (60 mg daily)
- Lower dose prednisone (30 mg daily) with azathioprine (50 mg daily in US or 1-2 mg/kg daily in Europe)
- For less severe conditions, lower doses generally suffice 2
Condition-Specific Dosing
| Condition | Recommended Initial Dose | Maintenance/Taper |
|---|---|---|
| Autoimmune hepatitis | 30-60 mg daily | Taper to 20 mg and below, then reduce by 5 mg weekly until 10 mg/day, then by 2.5 mg weekly to 5 mg daily [1] |
| Rheumatoid arthritis | 5-10 mg daily | Can be maintained at doses <5 mg/day long-term [3,4] |
| Children with autoimmune conditions | 1-2 mg/kg daily (up to 60 mg) | Taper over 6-8 weeks to 0.1-0.2 mg/kg daily or 5 mg daily [1] |
Administration Guidelines
- Take in the morning before 9 am to minimize adrenal suppression 2
- Take with food or milk to reduce gastric irritation 2
- For multiple daily doses, administer at evenly spaced intervals throughout the day 2
- Consider twice daily administration for certain conditions as it may allow for lower total daily dosing (e.g., 2.5 mg twice daily instead of 5 mg once daily) 5
Tapering Protocol
- After favorable response, decrease initial dose in small increments at appropriate intervals
- For doses above 20 mg daily: reduce by one-third or one-quarter down to 15-20 mg daily
- From 20 mg daily: reduce by 5 mg every week until 10 mg/day
- From 10 mg daily: reduce by 2.5 mg weekly to 5 mg daily
- Below 5 mg: reduce by 1 mg monthly 6
Monitoring Requirements
- Blood pressure at each clinic visit
- Blood glucose levels (urine dipstick for glucose)
- Bone mineral density for long-term use (baseline and annual for patients on prolonged therapy) 1
- Signs of infection, mood changes, and sleep disturbances
- Weight and signs of cushingoid features
Precautions and Contraindications
- Never stop prednisone abruptly due to risk of adrenal insufficiency 6
- Use with caution in patients with:
- Anticipate hypothalamic-pituitary-adrenal axis suppression in patients receiving >7.5 mg prednisolone equivalent daily for more than 3 weeks 1
Common Adverse Effects
- Short-term: weight gain, mood changes, sleep disturbances, increased appetite
- Long-term: osteoporosis, hypertension, diabetes, cataracts, increased infection risk
- Higher doses (>10 mg daily) significantly increase adverse event risk (OR = 32.3) compared to doses of 5-10 mg daily (OR = 4.5) 7
Special Situations
Stress Dosing
For patients on chronic therapy undergoing surgery or acute illness:
- Consider increasing the dose for 3 days or switching to IV hydrocortisone
- For patients on 10 mg prednisone daily: give 25 mg hydrocortisone twice daily
- For patients on high-dose therapy: give 50 mg hydrocortisone three times daily 1
Alternate Day Therapy
- May reduce side effects while maintaining therapeutic benefit
- Administer twice the usual daily dose every other morning 2
- May be particularly useful for children to minimize growth suppression 1
Prednisone is a powerful medication that requires careful dosing, monitoring, and tapering. The combination regimen of prednisone with other immunosuppressants is associated with fewer corticosteroid-related side effects (10% versus 44%) and is often preferred for long-term management 1.