What is the maximum dose of prednisolone (corticosteroid) per day?

Maximum Dose of Prednisolone Per Day

The maximum daily dose of prednisolone for adults is typically 60 mg per day, though higher doses may be used in specific clinical scenarios requiring intensive anti-inflammatory effects. 1

General Dosing Guidelines

The FDA-approved prednisolone labeling indicates that dosing is highly variable and must be individualized based on the specific disease being treated and the patient's response. The initial dose may range from 5 mg to 60 mg prednisolone base per day 1.

Age-Specific Maximum Doses:

• Adults: Generally capped at 60 mg/day for most conditions 1
• Children:
  • Maximum 60 mg/day or 2 mg/kg/day (whichever is lower) 2
  • For nephrotic syndrome: 2 mg/kg/day with a maximum of 60 mg/day 3

Condition-Specific Dosing:

1. Asthma exacerbations:

   • Adults: 40-60 mg/day as a single or divided dose for 3-10 days 2
   • Children: 1-2 mg/kg/day (maximum 60 mg/day) for 3-10 days 2

2. Nephrotic syndrome:

   • Children: 2 mg/kg/day (maximum 60 mg/day) 3
   • Adults: Short-course burst of 40-60 mg/day for 3-10 days 2

3. Inflammatory conditions:

   • Bullous pemphigoid: 0.75-1 mg/kg/day (41-55 mg/day) for severe cases 3
   • Autoimmune hepatitis: 40 mg daily or 0.6-0.8 mg/kg daily 3
   • Colitis: 1-2 mg/kg/day 3

High-Dose Scenarios

In certain severe conditions, higher doses may be used:

• Multiple sclerosis relapses: Up to 1,250 mg/day has been used (though this is exceptionally high and not standard practice) 4
• Severe pemphigus: Some protocols have used up to 1-2 mg/kg/day, with treatment failure defined as failure to achieve control despite 3 weeks of prednisolone at 1.5 mg/kg/day 2, 3

Important Considerations

Administration:

• Single morning dose is preferred over divided doses when possible, as it causes less adrenal suppression and is more convenient 5
• For doses exceeding 60 mg/day, consider pulse therapy (intravenous methylprednisolone) instead of oral prednisolone 2

Monitoring for Adverse Effects:

• Higher doses and longer duration increase risk of adverse effects including:
  • Glucose metabolism abnormalities
  • Fluid retention
  • Weight gain
  • Mood alterations
  • Hypertension
  • Adrenal suppression
  • Growth suppression (in children)
  • Increased risk of infections 2

Tapering:

• After disease control, gradually taper the dose rather than stopping abruptly
• Typical tapering involves reducing by one-third or one-quarter down to 15 mg daily, then by smaller decrements 3
• About 50% of patients may relapse during dose reduction 3

Key Pitfalls to Avoid

1. Abrupt discontinuation: Never stop prednisolone abruptly due to risk of adrenal insufficiency

2. Prolonged high-dose therapy: Limit high-dose therapy to the shortest duration possible to minimize adverse effects

3. Inadequate monitoring: Regular monitoring of blood pressure, glucose levels, and signs of infection is essential during treatment

4. Failure to provide prophylaxis: Consider prophylaxis against Pneumocystis jirovecii in immunocompromised patients on higher doses

5. Inappropriate dosing in overweight patients: Consider dosing based on ideal body weight rather than actual body weight in significantly overweight patients 2

In conclusion, while the standard maximum dose of prednisolone is 60 mg/day for most conditions, the optimal dose should be the lowest effective dose that achieves disease control to minimize adverse effects.