What is the proper dosage and usage of Prednisone (corticosteroid medication)?

Prednisone Dosing and Usage

Prednisone dosing must be individualized based on the specific disease being treated, with initial doses ranging from 5-60 mg/day, administered as a single morning dose before 9 AM to minimize adrenal suppression. 1

General Dosing Principles

Timing and Administration

• Administer prednisone in the morning prior to 9 AM as a single daily dose to align with the body's natural cortisol peak (2 AM to 8 AM) and minimize adrenocorticoid suppression 1
• Take with food, milk, or immediately after meals to reduce gastric irritation 1
• When multiple daily doses are required, distribute evenly throughout the day 1

Initial Dosing Range

• Standard initial dosing: 5-60 mg/day depending on disease severity and type 1
• Higher initial doses may be required for severe conditions, while less severe situations generally require lower doses 1

Disease-Specific Dosing Regimens

Nephrotic Syndrome (Children)

Initial Episode:

• 60 mg/m² or 2 mg/kg/day (maximum 60 mg/day) as single daily dose for 4-6 weeks 2
• Important caveat: These two dosing methods are NOT equivalent - the weight-based dosing (2 mg/kg) delivers significantly less medication than BSA-based dosing (60 mg/m²) in children <30 kg, with a median ratio of 0.85 3
• After initial phase: 40 mg/m² or 1.5 mg/kg on alternate days (maximum 40 mg) for 2-5 months with tapering 2
• Total treatment duration: at least 12 weeks 2

Infrequent Relapses:

• 60 mg/m² or 2 mg/kg daily (maximum 60 mg/day) until complete remission for at least 3 days 2
• Then 40 mg/m² or 1.5 mg/kg on alternate days (maximum 40 mg) for at least 4 weeks 2

Frequently Relapsing/Steroid-Dependent:

• Daily prednisone until remission for at least 3 days, followed by alternate-day dosing for at least 3 months 2
• Maintain on lowest effective alternate-day dose to prevent major adverse effects 2

Acute Gout

• 0.5 mg/kg/day for 5-10 days, then discontinue (preferred regimen) 2
• Alternative: 2-5 days at full dose, followed by 7-10 day taper 2
• Methylprednisolone dose pack is an acceptable option according to provider/patient preference 2
• Important limitation: Standard Medrol dose pack (84 mg methylprednisolone over 6 days ≈ 105 mg prednisone equivalent) may be underdosed compared to recommended therapeutic doses 4

Multiple Sclerosis Acute Exacerbations

• 200 mg prednisolone daily for 1 week, followed by 80 mg every other day for 1 month 1
• Prednisone and prednisolone dosing is equivalent 1
• High-dose oral prednisone (1,250 mg/day) shows excellent compliance (94.3%) and is acceptable to patients 5

Rheumatoid Arthritis

• Low-dose therapy: ≤10 mg/day, often 5 mg twice daily 6
• Ultra-low dose: <5 mg/day for long-term maintenance is safe and effective 7
• Should be initiated early, usually with another DMARD 6
• Taper slowly using 1 mg decrements every 2-4 weeks 6

Tapering and Discontinuation

Critical Principles

• Never abruptly discontinue after long-term therapy - withdraw gradually 1
• After favorable response, decrease in small increments at appropriate intervals to find the lowest effective maintenance dose 1
• Constant monitoring is essential for dosage adjustments based on disease activity, patient responsiveness, and stress exposure 1

Alternate-Day Therapy

• Administer twice the usual daily dose every other morning for long-term treatment 1
• Benefits: Minimizes pituitary-adrenal suppression, Cushingoid features, withdrawal symptoms, and growth suppression in children 1
• Rationale: Anti-inflammatory effects persist longer than metabolic effects, allowing HPA axis recovery on off-steroid days 1

Monitoring and Prevention of Adverse Effects

Infection Risk Management

• High-dose (>30 mg prednisone equivalent) for >4 weeks OR moderate-dose (15-30 mg) for ≥8 weeks requires:
  • Screening for tuberculosis, hepatitis B, Strongyloides stercoralis 8
  • Consider PJP prophylaxis, especially with combination immunosuppression 8
• Discontinue immunosuppression during active infection 8
• Maintain age-appropriate immunization schedule 8

Bone Health

• Initiate calcium 800-1,000 mg/day and vitamin D 400-800 units/day with all prednisone treatment 6

Common Side Effects

• Most frequent: Insomnia, mood changes, increased appetite, hyperglycemia, weight gain 4, 5
• Long-term low-dose (<5 mg/day): Primarily bruising and skin-thinning, with low rates of hypertension, diabetes, and cataracts 7

Critical Pitfalls to Avoid

1. Dosing discrepancies in children: BSA-based and weight-based dosing are not interchangeable - BSA dosing delivers more medication in children <30 kg 3

2. Timing errors: Morning administration is crucial to minimize adrenal suppression 1

3. Inadequate treatment duration: Extending steroid therapy beyond initial response in nephrotic syndrome decreases long-term relapse risk 2

4. Abrupt discontinuation: Always taper gradually after long-term use 1

5. Forgetting prophylaxis: Calcium/vitamin D supplementation and infection screening are essential 6, 8