Switching Prednisone 5mg Daily to Every Other Day
Yes, you can switch from prednisone 5mg daily to every other day in most clinical situations, as alternate-day dosing at low doses is an established strategy to minimize side effects while maintaining disease control. 1
Rationale for Alternate-Day Dosing at 5mg
The FDA label explicitly supports alternate-day therapy as a legitimate dosing regimen designed to minimize pituitary-adrenal suppression, Cushingoid effects, and growth suppression while maintaining therapeutic benefit. 1 The anti-inflammatory effects of corticosteroids persist longer than their physical presence in the body, and alternate-day dosing allows for re-establishment of more normal hypothalamic-pituitary-adrenal (HPA) axis activity on the off-steroid day. 1
Disease-Specific Considerations
For Nephrotic Syndrome in Children
- After achieving remission with daily dosing, guidelines strongly recommend transitioning to alternate-day prednisone (40 mg/m² or 1.5 mg/kg per dose, maximum 40mg) for maintenance therapy. 2
- For frequently relapsing or steroid-dependent cases, alternate-day prednisone should be given at the lowest dose to maintain remission without major adverse effects. 2
For Polymyalgia Rheumatica
- Single daily dosing is preferred over divided doses except for special situations such as prominent night pain while tapering below 5mg daily. 2, 3
- At 5mg daily, the European League Against Rheumatism suggests considering alternate-day schedules (e.g., 10/7.5mg on alternate days) as a practical approach when 1mg tablets are unavailable. 2
For Autoimmune Hepatitis
- In children, maintenance therapy can be reduced to 0.1-0.2 mg/kg daily or 5mg daily, with some centers advocating for alternate-day regimens to minimize effects on growth and bone development. 2
Practical Implementation Strategy
When converting from 5mg daily to alternate-day dosing:
Double the dose to 10mg every other day rather than continuing 5mg every other day, as the FDA label recommends administering twice the usual daily dose every other morning for alternate-day therapy. 1
Administer the dose in the morning (prior to 9am) to minimize adrenal suppression, as maximal adrenal cortex activity occurs between 2am and 8am. 1
Monitor for symptom flare-ups on the off-steroid day, as some patients may experience increased symptoms during the latter part of the off-steroid day. 1
If symptoms worsen significantly, return to daily dosing temporarily until control is re-established, then attempt alternate-day therapy again. 1
Critical Caveats and Contraindications
Do not attempt alternate-day conversion in these situations:
Steroid-dependent nephrotic syndrome where alternate-day therapy has already failed to maintain remission - these patients require daily dosing at the lowest effective dose. 2
Active disease flare or inadequate disease control - establish control with daily dosing first before attempting alternate-day therapy. 1
Patients with prominent night pain or symptoms - these patients may require continued daily dosing even at low doses. 2, 3
Monitoring Requirements
After switching to alternate-day dosing:
Assess disease activity markers within 2-4 weeks to ensure adequate control is maintained. 3
Educate patients about potential symptom fluctuation on off-steroid days and when to contact you. 1
If alternate-day therapy fails, return to daily dosing and consider adding steroid-sparing agents rather than increasing prednisone dose. 2
Common Pitfall to Avoid
The most common error is simply giving 5mg every other day instead of 10mg every other day. The FDA label is clear that alternate-day therapy involves administering twice the usual daily dose every other morning, not the same dose less frequently. 1 This approach maintains therapeutic efficacy while allowing HPA axis recovery on off days.