Is it better to take prednisolone (corticosteroid) in the morning or at night?

When to Take Prednisolone: Morning or Night

Prednisolone should typically be taken as a single dose in the morning upon awakening (around 7:00 AM) to mimic the body's natural cortisol rhythm and minimize side effects. 1

General Dosing Principles

• Prednisolone for adrenal insufficiency is typically administered as a single morning dose of 4-5 mg upon awakening 1, 2
• In some cases, a split dosing regimen may be used with 3 mg in the morning and 1-2 mg at 14:00 (2:00 PM) for patients experiencing energy fluctuations throughout the day 1, 2
• Morning dosing helps mimic the natural circadian rhythm of cortisol, which peaks in the early morning and reaches its lowest point at midnight 1

Benefits of Morning Administration

• Morning administration aligns with the body's natural cortisol rhythm, which may reduce HPA axis suppression 1, 3
• Taking prednisolone in the morning minimizes insomnia that can occur with evening dosing 1
• For patients with adrenal insufficiency, morning dosing helps prevent symptoms of under-replacement such as lethargy, nausea, poor appetite, and weight loss 1

Special Circumstances for Evening Dosing

• For patients with rheumatoid arthritis, nighttime administration of prednisolone may result in significantly shorter duration of morning stiffness compared to morning dosing 4, 5
• A modified-release prednisone formulation taken at bedtime (with 4-hour delayed release) has shown better control of morning stiffness in rheumatoid arthritis patients 5
• Patients working night shifts should adjust their dosing schedule according to their work pattern, taking the medication upon awakening before going to work 1

Specific Situations and Adjustments

• For patients experiencing morning nausea or lack of appetite (common in primary adrenal insufficiency), waking up earlier to take the first dose and then going back to sleep may help relieve these symptoms 1
• Patients with marked fluctuations in energy or well-being throughout the day may benefit from divided dosing 1
• The last dose of the day should be taken approximately 4-6 hours before bedtime to minimize sleep disturbances 1

Monitoring and Side Effects

• Signs of over-replacement include weight gain, insomnia, and peripheral edema 1
• Signs of under-replacement include lethargy, nausea, poor appetite, weight loss, and increased pigmentation 1
• Fine-tuning of dosage should be based on clinical assessment rather than laboratory values, as plasma ACTH and serum cortisol are not useful parameters for glucocorticoid dose adjustment 1

Potential Pitfalls and Caveats

• Abrupt discontinuation of prednisolone can lead to adrenal crisis in patients with adrenal insufficiency 1, 2
• Certain medications can affect prednisolone metabolism, requiring dose adjustments:
  • Anti-epileptics, barbiturates, and antituberculosis drugs may require increased prednisolone doses 1, 2
  • Grapefruit juice and licorice may require decreased prednisolone doses 1, 2
• Patients should be educated on dose adjustments during illness or stress and should wear medical alert identification 1, 2