Can I start prednisone (corticosteroid) at 60 mg at night?

Can You Start Prednisone 60 mg at Night?

Yes, you can start prednisone 60 mg at night, and for certain conditions this timing may actually be superior to morning dosing, particularly for reducing morning symptoms like stiffness. However, the standard recommendation from FDA labeling and most guidelines is morning administration to minimize adrenal suppression 1.

Timing Considerations Based on Evidence

Morning Dosing (Standard Recommendation)

• The FDA label explicitly recommends prednisone be administered in the morning prior to 9 am when given as a single daily dose, as this timing suppresses adrenocorticoid activity the least 1.
• The rationale is that maximal adrenal cortex activity occurs between 2 am and 8 am, and exogenous corticosteroids suppress this activity least when given during peak physiologic activity 1.
• For sudden hearing loss, guidelines recommend immediate high-dose treatment (prednisone 1 mg/kg/day with usual maximum of 60 mg/day) as a single morning dose, not divided 2.

Night Dosing (Evidence for Specific Benefits)

• For rheumatoid arthritis patients on low-dose prednisone, night dosing resulted in significantly shorter duration of morning stiffness (p = 0.0001) compared to morning dosing 3.
• This benefit appears specific to conditions where morning symptoms are the primary concern 3.

Single vs. Divided Dosing

• Single daily dosing is strongly preferred over divided doses because it causes less adrenal suppression and is more convenient 1, 4.
• A randomized trial in proctocolitis showed 40 mg prednisolone as a single morning dose was equally effective as 10 mg four times daily, with no difference in side effects 4.

Disease-Specific Dosing at 60 mg

When 60 mg is Appropriate

• For autoimmune hepatitis in patients intolerant of azathioprine, the recommended initial dose is 60 mg/day, reducing over 4 weeks to 20 mg/day 2.
• For sudden hearing loss, prednisone 1 mg/kg/day (usual maximum 60 mg/day) is recommended for 7-14 days, then tapered 2.
• Maximum daily doses vary by condition, but 60 mg falls within the high-dose range (>30 mg/day) for most indications 5.

Duration and Tapering from 60 mg

• Full dose should be maintained for 7-14 days, then tapered over a similar time period 2.
• For autoimmune hepatitis, one representative regimen uses maximum dose for 4 days, followed by 10 mg taper every 2 days 2.
• Initial tapering should aim to reduce to 10 mg/day within 4-8 weeks, then slower tapering at 1 mg every 4 weeks to minimize adrenal insufficiency risk 6.

Critical Safety Considerations

Gastric Protection

• Gastric irritation may be reduced if taken before, during, or immediately after meals or with food or milk 1.
• When large doses are given, administration of antacids between meals helps prevent peptic ulcers 1.

Monitoring Requirements

• Patients on long-term corticosteroid treatment require calcium and vitamin D supplementation 2.
• Bone DEXA scanning should be performed at 1-2 yearly intervals while on steroids 2.
• Adrenal suppression risk is anticipated in any patient receiving >7.5 mg daily for >3 weeks 5.

Withdrawal Precautions

• Never stop abruptly—if after long-term therapy the drug is to be stopped, it must be withdrawn gradually rather than abruptly 1.
• Tapering by 1 mg every 4 weeks when reducing below 10 mg minimizes adrenal insufficiency risk 5, 6.

Common Pitfalls to Avoid

• Underdosing when switching between corticosteroids: Prednisone 60 mg equals methylprednisolone 48 mg or dexamethasone 10 mg 2.
• Divided dosing: This increases adrenal suppression without improving efficacy 1, 4.
• Tapering too quickly, especially at doses below 10 mg, which increases risk of adrenal insufficiency and disease relapse 6.
• Failing to provide gastric protection with high-dose therapy 1.

Practical Recommendation

For most conditions requiring 60 mg prednisone, start with morning dosing (before 9 am) as a single daily dose with food 1. Night dosing at 60 mg should be reserved for specific situations where morning symptoms (like stiffness) are the primary therapeutic target, recognizing this may cause more adrenal suppression 3. The choice should be individualized based on the specific disease being treated and symptom pattern, but when in doubt, default to morning administration per FDA guidance 1.