What is the dosage and usage of Hydroxyprednisolone (Prednisolone)?

Prednisolone Dosage and Usage

Prednisolone and prednisone are pharmacologically equivalent and interchangeable at the same dosage, with the choice between them typically depending on geographic availability rather than clinical superiority. 1

Pharmacological Equivalence

• Prednisone and prednisolone are equivalent medications used at identical doses, with both having been validated in randomized controlled trials depending on country of origin. 2, 1
• Prednisone is more commonly prescribed in the United States, while prednisolone predominates in Europe and other regions. 1
• 5 mg prednisolone is equivalent to 20 mg hydrocortisone or 4 mg methylprednisolone. 2, 3
• For comparison purposes, 15 mg prednisolone equals 15 mg prednisone, 12 mg methylprednisolone, 60 mg hydrocortisone, 2.25 mg dexamethasone, or 2.25 mg betamethasone. 3

Standard Dosing by Indication

Nephrotic Syndrome and FSGS

• Initial dose: 1 mg/kg/day (maximum 80 mg) as a single daily dose, or 2 mg/kg alternate-day (maximum 120 mg). 2, 1
• Maintain the initial high dose for a minimum of 4 weeks if complete remission is achieved, and for a maximum of 16 weeks if complete remission is not achieved. 2
• After achieving remission, taper slowly over up to 6 months total. 2

Asthma Exacerbations

• Adults: 40-60 mg/day as a single dose or divided into 2 doses for 3-10 days. 2
• Children: 1-2 mg/kg/day in single or divided doses (maximum 60 mg/day) for 3-10 days. 2, 3
• No tapering is required after short courses (3-10 days) as there is no evidence that tapering prevents relapse. 2, 3

Tuberculous Pericarditis

• Adults: 60 mg/day for 4 weeks, then 30 mg/day for 4 weeks, then 15 mg/day for 2 weeks, then 5 mg/day for the final week (11 weeks total). 2
• Children: approximately 1 mg/kg body weight initially, with proportionate tapering as described for adults. 2
• This regimen reduces mortality (4% vs 11% with placebo) and need for repeated pericardiocentesis. 2

Rheumatoid Arthritis (Low-Dose Maintenance)

• Low-dose therapy: 5-10 mg daily or 5 mg twice daily controls inflammatory features in early polyarticular disease. 4, 5
• Doses ≤15 mg daily show marked superiority over placebo for joint tenderness (12 fewer tender joints), pain, and grip strength (22 mm Hg improvement). 6, 5
• Low-dose prednisolone is also superior to NSAIDs for joint tenderness (9 fewer tender joints) and pain. 6, 5

COPD Exacerbations

• 5 days of systemic corticosteroid treatment is sufficient and equivalent to longer 10-14 day courses. 7
• Typical dosing: 30-40 mg/day prednisolone for 5 days. 7
• Shorter courses reduce cumulative adverse effects without compromising efficacy for treatment failure, relapse risk, or time to next exacerbation. 7

Severe Urticaria/Angioedema

• Emergency treatment: 50-100 mg prednisolone equivalent as a single dose. 8
• For severe cases requiring higher doses, >250 mg may be administered orally with symptom remission of at least 50% occurring within 30 minutes. 8
• Liquid formulations are advantageous when dysphagia is present. 8

Pemphigus Vulgaris

• Initial therapy: 1-2 mg/kg/day (most clinicians use 1 mg/kg/day). 2
• For milder cases, 0.5-1 mg/kg/day may be appropriate. 2
• If no response within 5-7 days, increase dose in 50-100% increments until disease control is achieved (defined as no new lesions and healing of pre-existing ones). 2
• Treatment failure is defined as lack of disease control despite 3 weeks of 1.5 mg/kg/day prednisolone. 2

Sudden Sensorineural Hearing Loss

• Prednisone 1 mg/kg/day (usual maximum 60 mg/day) for 7-14 days, then taper over a similar period. 2
• Alternative regimens: maximum dose for 4 days, followed by 10 mg taper every 2 days. 2
• Equivalent doses: 60 mg prednisone = 48 mg methylprednisolone = 10 mg dexamethasone. 2
• Treatment should ideally begin within the first 14 days, though benefit has been reported up to 6 weeks. 2

Pediatric Dosing Principles

• General range: 0.14-2 mg/kg/day in 3-4 divided doses (equivalent to 4-60 mg/m²/day BSA). 3
• Nephrotic syndrome standard regimen: 60 mg/m²/day in 3 divided doses for 4 weeks, followed by 40 mg/m²/day as single-dose alternate-day therapy for 4 weeks. 3
• For asthma uncontrolled by inhaled corticosteroids: 1-2 mg/kg/day in single or divided doses. 3

Perioperative Management in IBD

• Patients on corticosteroids for >4 weeks prior to surgery should receive equivalent intravenous hydrocortisone while nil by mouth perioperatively. 2
• For elective surgery, corticosteroids should be stopped or minimized preoperatively to reduce postoperative complications. 2
• Doses ≥40 mg prednisolone are associated with increased risk of postoperative infections, VTE, and anastomotic leak. 2
• There is no value in increasing steroid dosage to cover perioperative stress, as demonstrated in randomized trials. 2
• After complete resection of active disease, implement standardized taper protocols to avoid inappropriate prolongation of steroids. 2

Tapering Guidelines

• For courses >2-3 weeks, gradual tapering is essential to prevent adrenal insufficiency. 3
• Initial tapering should aim to reduce to 10 mg/day within 4-8 weeks, then slower tapering at 1 mg every 4 weeks. 1
• Short courses (≤7 days) typically do not require tapering. 2, 3
• If stopping after long-term therapy, withdraw gradually rather than abruptly. 3

Important Caveats and Monitoring

• Dosage requirements are highly variable and must be individualized based on disease severity and patient response. 3
• Constant monitoring is needed for changes in clinical status, disease exacerbations, or exposure to stressful situations. 3
• For patients with relative contraindications (uncontrolled diabetes, psychiatric conditions, severe osteoporosis), consider alternative immunosuppressive agents. 2
• Most serious adverse effects occur with chronic use; short courses (10-14 days) have acceptable and manageable side effects. 2
• With concomitant calcium and vitamin D supplementation and DEXA monitoring, osteopenia risk from low-dose prednisolone is minimal. 4
• Using low-dose prednisolone without NSAIDs reduces risk of gastric ulceration and bleeding. 4