What are the typical dosages and uses of glucocorticoids (e.g. prednisone) and mineralocorticoids (e.g. fludrocortisone) in clinical practice?

Glucocorticoids and Mineralocorticoids: Typical Dosages and Clinical Uses

Glucocorticoids (e.g., prednisone) and mineralocorticoids (e.g., fludrocortisone) have distinct dosing regimens and clinical applications, with dosages that should be tailored based on the specific condition being treated and patient factors.

Glucocorticoid (Prednisone) Dosing and Uses

Dosage Categories

• Low-dose: ≤7.5 mg/day prednisone equivalent 1
• Medium-dose: >7.5 mg/day to ≤30 mg/day prednisone equivalent 1
• High-dose: >30 mg/day to ≤100 mg/day prednisone equivalent 1

Common Dosing Regimens by Condition

Rheumatoid Arthritis and Other Inflammatory Conditions

• Initial dose: 15-20 mg/day (often 1 mg/kg up to 60 mg) with rapid reduction 1
• Maintenance: Taper to 15 mg by 12 weeks, then gradually reduce to ≤10 mg/day 1
• Long-term goal: Lowest effective dose (ideally ≤5 mg/day) or complete withdrawal 1, 2

ANCA-Associated Vasculitis

• Remission induction: 1 mg/kg/day (maximum 60-75 mg/day) for 1 month 1
• Maintenance: Taper to 15 mg by 12 weeks, then gradually to 5 mg/day 1
• Reduced-dose regimen (from PEXIVAS trial): 50% reduction in second week with more rapid tapering, reaching 5 mg/day by week 15 1

Polymyalgia Rheumatica

• Initial dose: 12.5-25 mg/day (within 10-20 mg/day range) 1
• Taper: Reduce by 1 mg every 4 weeks once remission is achieved 1
• Avoid high doses (>30 mg/day) as they increase risk without additional benefit 1

Duchenne Muscular Dystrophy

• Daily dose: 0.75 mg/kg/day (0.3-0.6 mg/kg/day minimum effective dose) 1
• Alternative regimens: 0.75-1.25 mg/kg every other day or 5 mg/kg on weekends only 1

Administration Considerations

• Morning dosing (before 9 AM) is preferred to align with natural cortisol rhythm 3
• For divided doses, use larger portion in morning (e.g., 10 mg morning, 5 mg noon, 2.5 mg afternoon) 3
• Take with food or milk to reduce gastric irritation 3

Mineralocorticoid (Fludrocortisone) Dosing and Uses

Primary Adrenal Insufficiency

• Standard dose: 0.05-0.2 mg (50-200 μg) once daily in the morning 4, 5
• Always given in combination with glucocorticoid replacement (typically hydrocortisone 15-25 mg/day) 6, 5
• Higher doses (up to 500 μg daily) may be needed in children, younger adults, or during pregnancy 4, 6

Salt-Losing Adrenogenital Syndrome

• Recommended dose: 0.1-0.2 mg daily 5

Dose Adjustment Parameters

• Increase dose for: orthostatic hypotension, salt cravings, low sodium, high potassium, high plasma renin activity 4, 7
• Decrease dose for: hypertension, peripheral edema, low potassium 4, 7
• Monitor: blood pressure (both supine and standing), serum electrolytes, clinical symptoms 4, 6

Side Effects and Risk Management

Glucocorticoid Side Effects (Dose-Dependent)

• Infections: Even low doses (≤5 mg/day) increase risk of serious infections (8.6% vs. 11.0% annual incidence) 8
• Osteoporosis: 1-3 events per 100 patient-years with chronic medium-dose therapy 1
• Diabetes: 0-13 events per 100 patient-years with chronic medium-dose therapy 1
• Hypertension: 0-63 events per 100 patient-years with chronic medium-dose therapy 1

Mineralocorticoid Side Effects

• Hypertension (most common) 4
• Peripheral edema 4
• Hypokalemia 4, 7

Risk Mitigation Strategies

• Use lowest effective glucocorticoid dose for shortest duration possible 1
• Consider alternate-day dosing when appropriate to reduce side effects 1, 3
• For adrenal insufficiency patients on fludrocortisone: avoid potassium-containing salt substitutes and medications that interact with mineralocorticoids (diuretics, NSAIDs) 4, 6
• Monitor for adrenal insufficiency in patients on chronic glucocorticoid therapy (>7.5 mg prednisolone equivalent daily for >3 weeks) 1

Special Considerations

Stress Dosing in Adrenal Insufficiency

• Increase glucocorticoid dose during acute illness, surgery, or trauma 1, 6
• For minor stress: double or triple usual daily dose for 3 days 1
• For major stress: switch to IV hydrocortisone (e.g., 50 mg twice daily for patients on 10 mg prednisone) 1

Pregnancy Considerations

• Fludrocortisone dose may need to be increased (up to 500 μg daily) in the third trimester due to progesterone's antimineralocorticoid effects 4, 6

Tapering Considerations

• Never stop glucocorticoids abruptly after prolonged use 1, 3
• Taper more slowly at lower doses (below 7.5 mg/day) 1
• Consider stress-dose steroids for up to 1 year after discontinuation of long-term therapy 1