What is the recommended dose of prednisolone (corticosteroid) in Rheumatoid Arthritis (RA)?

Prednisolone Dosing in Rheumatoid Arthritis

For rheumatoid arthritis, prednisolone should be initiated at low doses of 5-10 mg daily (not exceeding 10 mg/day), preferably given in divided doses (5 mg twice daily), and tapered slowly to the lowest effective maintenance dose, typically less than 5 mg/day for long-term use. 1, 2

Initial Dosing Strategy

• Start with 5-10 mg/day of prednisone/prednisolone, with most patients responding well to doses at or below 10 mg daily 1, 2
• Consider divided dosing (5 mg twice daily) rather than a single morning dose, as this may provide better control of inflammation throughout the day 1
• Never exceed 10 mg/day for routine RA management, as higher doses increase adverse effects without proportional benefit 1
• The FDA label indicates initial doses may range from 5-60 mg/day depending on disease severity, but for RA specifically, the lower end of this range is appropriate 3

Rationale for Low-Dose Approach

• Low-dose glucocorticoids (≤10 mg/day) effectively suppress RA inflammation and have been shown to retard radiographic progression of bony erosions, making them true disease-modifying agents 1, 2, 4
• Twelve clinical trials have documented that prednisone/prednisolone at 10 mg/day or less improves function, maintains disease control, and slows radiographic progression 4
• Doses of 5 mg/day or even 3 mg/day have proven effective in controlled trials, with one withdrawal study showing patients on just 3 mg/day had significantly worse outcomes when withdrawn to placebo 4
• Low-dose prednisone accomplishes everything NSAIDs achieve but with greater anti-inflammatory effects, fewer side effects, and lower cost 2

Tapering and Maintenance

• Taper slowly using 1 mg decrements every 2-4 weeks once disease control is achieved 1
• Aim for maintenance doses below 5 mg/day for long-term therapy, as this minimizes adverse effects while maintaining efficacy 5
• Do not consider it a failure to maintain patients on the lowest effective dose indefinitely—many patients require long-term low-dose therapy 1, 5
• Over 25 years of clinical experience shows that maintenance doses averaging 3.6 mg/day can provide sustained disease control with acceptable safety 5

Combination Therapy

• Always initiate prednisone with a DMARD (typically methotrexate) as early as possible in RA treatment 1
• Low-dose prednisone likely enhances the effects of other DMARDs, including anti-TNF agents 2
• The CAMERA-II study demonstrated that adding 10 mg prednisone to a treat-to-target methotrexate strategy provided incremental slowing of radiographic progression 4

Bone Protection (Essential)

• Mandatory: Initiate calcium 800-1,000 mg/day and vitamin D 400-800 units/day with all glucocorticoid therapy 1
• Monitor bone density with DEXA scans to minimize osteopenia risk 2
• With appropriate calcium/vitamin D supplementation, the osteopenia potential of low-dose prednisone is minimal 2

Timing Considerations

• Modified-release prednisone taken at bedtime may be superior to morning dosing, leading to lower morning stiffness and IL-6 levels 4
• An early trial showed that 5 mg prednisolone at night was preferred to 5 mg prednisone in the morning 4

Common Pitfalls to Avoid

• Do not use doses exceeding 10 mg/day routinely—this increases adverse effects without proportional benefit 1
• Do not taper too quickly—rapid withdrawal increases relapse risk; use 1 mg decrements over weeks to months 1
• Do not omit bone protection—always prescribe calcium and vitamin D from day one 1, 2
• Do not avoid glucocorticoids entirely—they are highly effective disease-modifying agents when used appropriately at low doses 2, 4

Safety Profile

• Adverse effects at doses <5 mg/day are primarily bruising and skin-thinning, with low rates of hypertension, diabetes, and cataracts 5
• The risk of gastric ulceration and bleeding is very low with low-dose prednisone alone (without NSAIDs) 2
• Long-term use at doses <5 mg/day appears acceptable and effective for many RA patients 5

Evidence Quality Note

The evidence provided includes polymyalgia rheumatica (PMR) guidelines 6, 7, 8, 9, which recommend higher initial doses (12.5-25 mg/day). These PMR recommendations should not be applied to RA, as RA requires lower doses. The RA-specific research consistently supports maximum doses of 10 mg/day or less 1, 2, 4, 5, 10.