What is the typical dosing range for prednisolone (corticosteroid)?

Prednisolone Dosing Guidelines

Prednisolone dosing is highly disease-specific and weight-based, typically ranging from 0.3 mg/kg/day for mild conditions to 2 mg/kg/day for severe autoimmune diseases, with the FDA label indicating a general range of 5-60 mg/day (0.14-2 mg/kg/day in pediatrics) that must be individualized based on disease severity and patient response. 1

Disease-Specific Dosing Recommendations

Autoimmune Blistering Diseases

Bullous Pemphigoid:

• Severe/widespread disease: 0.75-1 mg/kg/day 2, 3
• Moderate disease: 0.3 mg/kg/day 2, 3
• Mild/localized disease: 0.5 mg/kg/day 2, 3
• Response typically occurs within 1-4 weeks in 60-90% of cases 2
• Tapering protocol: Reduce by one-third to one-quarter every 2 weeks down to 15 mg daily, then by 2.5 mg decrements to 10 mg daily, followed by 1 mg monthly reductions 2, 3

Pemphigus Vulgaris:

• Standard initial dose: 1-2 mg/kg/day, with most experienced clinicians choosing 1 mg/kg/day 2, 3
• Milder cases: 0.5-1 mg/kg/day 2, 3
• If no response within 5-7 days, increase dose in 50-100% increments until disease control achieved 2
• Treatment failure definition: No response after 3 weeks at 1.5 mg/kg/day 2, 3
• Consider pulsed IV corticosteroids if doses above 1 mg/kg/day are required 2

Inflammatory Myopathies

Dermatomyositis/Polymyositis:

• Initial dose: 0.5-1 mg/kg/day (typically 60-80 mg/day for a 70 kg patient) as single daily dose 2
• Tapering schedule: After 2-4 weeks of response, reduce by 10 mg every 2 weeks to 30 mg/day, then by 5 mg every 2 weeks to 20 mg/day, then by 2.5 mg every 2 weeks until completion 2
• At 10 mg/day, may slow taper to 1 mg every 2-4 weeks 2
• Always initiate concurrent steroid-sparing agent (methotrexate, azathioprine, or mycophenolate) 2

Pediatric Conditions

Nephrotic Syndrome:

• Initial phase: 60 mg/m² or 2 mg/kg/day (maximum 60 mg/day) as single daily dose for 4-6 weeks 3, 4, 1
• Maintenance phase: 40 mg/m² or 1.5 mg/kg on alternate days (maximum 40 mg) for 2-5 months with gradual tapering 3, 4

Asthma Exacerbations:

• Dose: 1-2 mg/kg/day (maximum 60 mg/day) until peak expiratory flow reaches 80% of personal best or symptoms resolve, typically 3-10 days 4, 1
• No evidence that tapering after improvement prevents relapse 1

Other Conditions

Autoimmune Hepatitis:

• Initial: 30 mg/day, reducing to 10 mg/day over 4 weeks 4
• Maintenance: 5-10 mg/day for at least 2 years 4

Multiple Sclerosis Acute Exacerbations:

• 200 mg daily for 1 week, followed by 80 mg every other day for 1 month 1

Critical Dosing Principles

Dose Escalation Strategy

• If no response within 5-7 days at initial dose, increase by 50-100% increments 2
• For doses exceeding 1 mg/kg/day (or 100 mg/day), strongly consider pulsed IV methylprednisolone (250-1000 mg for 2-5 days) rather than further oral escalation 2

Maintenance and Long-Term Therapy

• Low maintenance doses (<5 mg/day) are associated with acceptable long-term safety profiles 5
• Initial dose strongly predicts maintenance dose requirements 6
• Doses ≥5 mg/day show dose-dependent adverse events including fractures, infections, and GI complications 7
• For long-term therapy, alternate-day dosing may reduce adverse effects 4

Important Caveats

Mortality Risk:

• Very high doses (>1 mg/kg/day) carry significant mortality risk, particularly in elderly patients with comorbidities 2
• Up to 77% of deaths in pemphigus patients were corticosteroid-related in early high-dose studies 2
• One study using 1 g IV methylprednisolone daily showed 4 deaths among 8 patients with severe bullous pemphigoid 2

Dose-Response Paradox:

• In pemphigus vulgaris, one RCT showed no difference between low-dose (30-60 mg/day) and high-dose (120-180 mg/day) prednisolone for disease control or relapse rates at 5 years, with no deaths in either group 2
• The high-dose arm tapered more rapidly, resulting in lower cumulative steroid exposure by week 7 2

Bone Protection:

• All patients on long-term therapy require calcium and vitamin D supplementation 4
• DEXA scanning should be performed at 1-2 year intervals 4

Administration Considerations

• Prednisolone and prednisone are considered bioequivalent 2
• Single daily dosing is standard for most conditions 4, 1
• Some evidence suggests twice-daily fractionated dosing (e.g., 2 × 1.25 mg vs 1 × 4 mg) may allow lower total daily doses with equivalent efficacy 8