What are high-dose steroids?

What Constitutes High-Dose Steroids

High-dose steroids are generally defined as prednisone/prednisolone ≥20 mg/day for ≥2 weeks, or ≥2 mg/kg/day (maximum 60-80 mg/day) for acute treatment, though specific thresholds vary by clinical context and patient population. 1

Dosing Thresholds by Clinical Context

Pediatric Rheumatic Diseases

• High-dose glucocorticosteroids are defined as ≥2 mg/kg/day OR ≥20 mg/day for ≥2 weeks 1
• In children chronically treated with 20 mg/day, dosages below 2 mg/kg/day are also considered high doses due to cumulative exposure 1

Adult Autoimmune Conditions

For pemphigus vulgaris and bullous pemphigoid:

• Standard high-dose therapy: 1-2 mg/kg/day prednisolone (maximum 80-120 mg) 1
• Very high-dose therapy: Prednisolone >40 mg/day is associated with significantly increased mortality in elderly patients with bullous pemphigoid 1
• Pulse therapy: Intravenous methylprednisolone 10-20 mg/kg or 250-1000 mg for 2-5 consecutive days 1

For glomerulonephritis (FSGS, minimal change disease):

• High-dose oral therapy: 1 mg/kg/day prednisone (maximum 80 mg) or 2 mg/kg alternate-day (maximum 120 mg) 1

Acute Medical Conditions

For sudden hearing loss:

• Recommended dose: 1 mg/kg/day prednisone (usual maximum 60 mg/day) for 10-14 days 1
• Equivalent doses: Methylprednisolone 48 mg = Prednisone 60 mg = Dexamethasone 10 mg 1

For immunotherapy toxicities:

• Moderate neurological/cardiac toxicity: 0.5-1 mg/kg/day prednisolone 1
• Severe toxicity: 1-2 mg/kg/day prednisolone or IV equivalent 1

Chronic Obstructive Pulmonary Disease

• High-dose defined as: ≥30 mg/day prednisolone 2
• Low-dose: <10-15 mg/day prednisolone 2

Immunosuppression Thresholds

The critical threshold for significant immunosuppression and infection risk is prednisone ≥20 mg/day (or equivalent) for ≥4 weeks, or ≥15 mg/day for ≥8 weeks. 3

• Patients on >30 mg prednisone-equivalent dose (PEQ) for >4 weeks require screening and prophylaxis for tuberculosis, hepatitis B, Strongyloides, and Pneumocystis jirovecii pneumonia 3
• Patients on ≥15 to <30 mg PEQ for ≥8 weeks (chronic moderate-dose) also warrant consideration for antimicrobial prophylaxis 3

Steroid Potency Equivalents

When calculating high-dose thresholds, account for relative potencies 1:

• Hydrocortisone (cortisol): 1x baseline potency
• Prednisone/Prednisolone: 4x more potent than hydrocortisone
• Methylprednisolone: 5x more potent than hydrocortisone
• Dexamethasone: 25x more potent than hydrocortisone

Clinical Implications of High-Dose Therapy

High-dose steroids (≥20 mg/day prednisone for ≥2 weeks) require specific monitoring and prophylaxis:

• Measure pathogen-specific antibody concentrations after vaccination 1
• Withhold live-attenuated vaccines 1
• Consider bone protection (calcium, vitamin D, bisphosphonates) if therapy anticipated for ≥3 months at ≥5 mg/day prednisone-equivalent 4
• Monitor for hyperglycemia, hypertension, and infection risk 5, 3

Common Pitfalls

Avoid underdosing by failing to account for steroid potency equivalents. For example, a methylprednisolone dose pack (84 mg total over 6 days) provides only the equivalent of 105 mg prednisone, compared to 540 mg over 14 days for adequate treatment 1

Do not abruptly discontinue high-dose steroids. Patients on ≥20 mg/day for ≥2 weeks develop HPA axis suppression and require gradual tapering over weeks to months to prevent adrenal insufficiency 4, 6