Prednisone Dosing Based on Modified Rodnan Skin Score (mRSS)
For systemic sclerosis patients with skin involvement, prednisone dosing should be based on disease severity, with 0.5 mg/kg/day for mild disease (low mRSS), 0.75 mg/kg/day for moderate disease (intermediate mRSS), and 1 mg/kg/day for severe disease (high mRSS). 1
Dosing Algorithm Based on Disease Severity
Mild Disease (Low mRSS)
- Initial prednisone dose of 0.5 mg/kg/day 1
- Appropriate for patients with localized or limited skin involvement 1
- Consider topical steroids as adjunctive therapy for accessible lesions 1
Moderate Disease (Intermediate mRSS)
- Initial prednisone dose of 0.75 mg/kg/day 1
- For patients with more extensive skin involvement but without severe systemic manifestations 1
- Consider earlier addition of steroid-sparing agents 1
Severe Disease (High mRSS)
- Initial prednisone dose of 1 mg/kg/day (maximum 60 mg/day) 1
- For patients with extensive skin involvement and/or systemic manifestations 1
- Consider pulse methylprednisolone (1 g daily for 3 days) for rapidly progressive disease 1
Monitoring and Dose Adjustment
- Assess clinical response after 1-3 weeks of initial therapy 1
- If inadequate response to 0.5-0.75 mg/kg/day within 1-3 weeks, increase dose to the next level 1
- Begin tapering 15 days after disease control is achieved 1
- Taper gradually with aim of reaching minimal effective dose within 4-6 months 1
- For maintenance, aim for prednisone ≤10 mg/day 1
Long-term Management
- Continue maintenance therapy for at least 12 months after normalization of skin findings 1
- Consider steroid-sparing agents (e.g., azathioprine, mycophenolate) for patients requiring prolonged therapy 1
- Lower doses of prednisone (<5 mg/day) may be effective for long-term maintenance in some patients 2, 3
- Monitor for steroid-related adverse effects, particularly in patients on doses >5 mg/day for extended periods 4
Important Considerations
- Women report more intolerable adverse effects from prednisone than men (95% vs 81%) 4
- Provide calcium and vitamin D supplementation for all patients on prolonged steroid therapy 1
- Consider DEXA scanning at 1-2 year intervals for patients on long-term steroids 1
- Bisphosphonate prophylaxis is recommended for high-risk patients (postmenopausal women, men >50 years) on glucocorticoids >3 months 1
- Vaccination against influenza and pneumococci is recommended; live vaccines are contraindicated 1
Caution
- Higher doses of prednisone (>0.75 mg/kg/day) are associated with increased mortality and adverse effects 1
- Dosing based on body surface area (60 mg/m²) is not equivalent to weight-based dosing (2 mg/kg) in patients <30 kg 5
- Avoid rapid discontinuation of therapy; always taper gradually to prevent disease flare and adrenal insufficiency 1