What is the typical dosing range for prednisolone (corticosteroid)?

Prednisolone Dosing

Prednisolone dosing ranges from 5-60 mg/day (0.14-2 mg/kg/day) depending on the specific condition being treated, with most autoimmune conditions requiring 0.5-1 mg/kg/day initially, while long-term maintenance therapy typically uses ≤5 mg/day. 1

Initial Dosing by Condition

Autoimmune/Inflammatory Conditions

• Pemphigus vulgaris: Start with 1-2 mg/kg/day for severe disease; milder cases can be managed with 0.5-1 mg/kg/day 2
• Bullous pemphigoid:
  • Severe/widespread: 0.75-1 mg/kg/day 2
  • Moderate: 0.3 mg/kg/day 2
  • Mild/localized: 0.5 mg/kg/day 2
• Dermatomyositis/polymyositis: 0.5-1 mg/kg/day initially 2
• Lupus nephritis: 40-50 mg/day (approximately 0.6-0.7 mg/kg/day for a 70 kg patient) achieves superior complete renal response rates (61.8% vs 38.2%) compared to ≤30 mg/day at 12 months 3

Other Conditions

• Sudden hearing loss: 1 mg/kg/day (maximum 60 mg/day) for 7-14 days, then taper over a similar period 4
• Tuberculous pericarditis: 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 week 11 (reduces mortality from 14% to 3%) 4
• Pediatric asthma exacerbations: 1-2 mg/kg/day in single or divided doses for 3-10 days until symptoms resolve 1
• Pediatric nephrotic syndrome: 60 mg/m²/day in three divided doses for 4 weeks, followed by 40 mg/m²/day alternate-day therapy for 4 weeks 1

Critical Safety Thresholds

Never exceed 1 mg/kg/day without considering pulsed IV methylprednisolone due to significantly increased mortality risk, particularly in elderly patients with comorbidities. 2

• Doses above 0.75 mg/kg/day (52.5 mg/day for a 70 kg patient) provide no additional benefit in many conditions 4
• Doses above 30 mg/day are associated with significant mortality, especially in elderly patients 4
• If no response occurs within 5-7 days, increase by 50-100% increments, but consider IV pulsed corticosteroids if exceeding 1 mg/kg/day 2, 4

Maintenance Dosing

Long-term maintenance therapy should target ≤5 mg/day, which appears both effective and acceptable for most chronic conditions. 5

• Rheumatoid arthritis: <5 mg/day provides similar clinical improvements as ≥5 mg/day over 12 months with maintained benefits for >8 years 5
• Polymyalgia rheumatica/temporal arteritis: Mean maintenance doses are 5.7 mg/day (first year) and 4.3 mg/day (second year) for PMR; 6.6 mg/day and 4.1 mg/day for temporal arteritis 6
• Frequently relapsing nephrotic syndrome: 0.25 mg/kg/day for 18 months significantly reduces relapse frequency (0.5 vs 3.62 relapses/patient/year) 7
• Adrenal insufficiency replacement: 4-5 mg/day as single morning dose, or 3 mg morning plus 1-2 mg at 2 pm (hydrocortisone preferred; prednisolone only for selected cases with marked energy fluctuations) 4

Tapering Strategy

Reduce daily dose by one-third to one-quarter until reaching 15 mg/day, then by 2.5 mg steps until 10 mg/day, then by 1 mg/month until the minimum effective dose. 4

• Lower initial doses are associated with lower maintenance doses, which is clinically important since most patients require >2 years of treatment 6
• After long-term therapy, withdraw gradually rather than abruptly 1
• For short "burst" therapy (e.g., asthma), no evidence supports tapering after improvement to prevent relapse 1

Administration Modalities

• Single morning dose: Standard for most conditions 4
• Divided doses: May be necessary for severe diseases requiring continuous control 4
• Alternate-day dosing: Reduces adverse effects in long-term therapy 2, 4

Essential Monitoring and Prophylaxis

All patients on long-term therapy require mandatory calcium and vitamin D supplementation with regular DEXA scanning for osteoporosis prevention. 2, 4

• Most frequent side effects include hyperglycemia and weight gain, even with short courses 4
• Signs of overdose: weight gain, insomnia, peripheral edema 4
• Signs of underdose: lethargy, nausea, loss of appetite, weight loss, increased pigmentation 4
• Primary adverse effects with low-dose therapy: bruising and skin-thinning, with lower rates of hypertension, diabetes, and cataracts 5

Important Caveats

• A dose-response paradox exists in pemphigus vulgaris where low-dose and high-dose prednisolone show no difference in disease control or relapse rates at 5 years 2
• Prednisolone and prednisone are bioequivalent 2, 4
• Dosage requirements are highly variable and must be individualized based on disease severity and patient response, with constant monitoring needed 1