What is a suitable dose of prednisone for treating urticaria?

Prednisone Dosing for Urticaria

For urticaria, prednisone should be used at a dose of 0.5-1 mg/kg/day for short courses (3-10 days) only for acute exacerbations, while avoiding prolonged use due to adverse effects. 1

Appropriate Use of Corticosteroids in Urticaria

Corticosteroids should not be used as first-line therapy for urticaria but reserved for specific situations:

1. Indications for prednisone use:

   • Acute severe exacerbations not responding to antihistamines
   • Short-term bridging therapy while initiating other treatments
   • When rapid symptom control is needed

2. Recommended dosing:

   • Initial dose: 0.5-1 mg/kg/day (typically 25-60 mg/day for adults) 1
   • Duration: Short courses of 3-10 days 1
   • Administration: Take in the morning before 9 am to minimize adrenal suppression 2
   • Consider taking with food or milk to reduce gastric irritation 2

Treatment Algorithm for Urticaria

First-line Treatment:

• Second-generation H1 antihistamines (e.g., cetirizine 10 mg/day, loratadine 10 mg/day, fexofenadine 180 mg/day) 1

Second-line Treatment:

• Increase antihistamine dose up to 4 times the standard dose if symptoms persist 1

Third-line Treatment (when antihistamines fail):

• Add prednisone 0.5-1 mg/kg/day for short course (3-10 days) 1
• Taper dose gradually when discontinuing 2

Fourth-line Treatment (for refractory cases):

• Consider omalizumab (300mg subcutaneously every 4 weeks) 1
• Consider cyclosporine (up to 5mg/kg body weight) 1

Clinical Evidence Supporting Prednisone Use

• A study of patients with antihistamine-resistant chronic urticaria found that a short course of prednisone (starting with 25 mg/day for 3 days) induced remission in nearly 50% of patients 3
• In acute urticaria, a 4-day course of prednisone (20 mg twice daily) added to antihistamines significantly improved symptom control compared to antihistamines alone 4

Important Considerations and Precautions

• Avoid prolonged use of corticosteroids due to potential adverse effects including:

  • Adrenal suppression
  • Cushingoid features
  • Hyperglycemia
  • Hypertension
  • Osteoporosis
  • Increased infection risk

• Monitoring: Evaluate response to treatment after 2 weeks using validated tools such as the Urticaria Activity Score (UAS7) 1

• Tapering: When discontinuing prednisone after long-term therapy, withdraw gradually rather than abruptly to prevent adrenal insufficiency 2

• Special populations: For pediatric patients, use weight-based dosing 1

Common Pitfalls to Avoid

1. Overreliance on corticosteroids: Prednisone should not replace appropriate use of antihistamines as first-line therapy
2. Prolonged use: Extended corticosteroid therapy can lead to significant adverse effects
3. Abrupt discontinuation: Always taper prednisone after courses longer than 1 week
4. Failure to address underlying causes: Identify and address potential triggers of urticaria

Remember that the goal of prednisone therapy is to achieve rapid symptom control during acute exacerbations while working toward long-term management with safer medications.