What are the typical doses of prednisone (corticosteroid) and methylprednisolone (corticosteroid)?

Typical Doses of Prednisone and Methylprednisolone

Prednisone oral dosing typically ranges from 5-60 mg/day depending on disease severity, while methylprednisolone oral dosing ranges from 4-48 mg/day, with the critical conversion being that 4 mg methylprednisolone equals 5 mg prednisone. 1, 2

Standard Oral Dosing Ranges

Prednisone

• Initial dosing: 5-60 mg/day, individualized based on disease entity and severity 1
• Moderate disease: 0.5-1 mg/kg/day (typically 20-60 mg/day) 3
• Severe disease: 1-2 mg/kg/day (maximum 60 mg/day in most contexts) 3
• Low-dose maintenance: <5 mg/day for long-term use when necessary 4
• Administration timing: Single morning dose before 9 AM to minimize HPA axis suppression 1

Methylprednisolone

• Initial dosing: 4-48 mg/day orally 2
• Conversion: 4 mg methylprednisolone = 5 mg prednisone 2
• Equivalent moderate dosing: 0.5-1 mg/kg/day (16-48 mg/day) 3
• Administration timing: Single morning dose preferred 2

High-Dose Intravenous Pulse Therapy

Methylprednisolone IV

• Standard pulse: 500-1000 mg IV daily for 3 consecutive days 5
• Acute spinal cord injury: 30 mg/kg IV bolus, then 5.4 mg/kg/hour infusion for 24-48 hours 6
• Acute asthma: 40-250 mg IV (typically 125 mg) 5
• After IV pulses: Transition to oral prednisone 0.3-0.5 mg/kg/day (20-40 mg/day) 5

High-Dose Oral Prednisone

• MS relapses: 1,250 mg/day (25 tablets of 50 mg) for 3-5 days, or 200 mg/day for 1 week followed by 80 mg every other day for 1 month 1, 7
• Equivalent to IV therapy: High-dose oral prednisone shows similar efficacy to IV methylprednisolone for certain conditions 7

Disease-Specific Dosing Examples

Immune Checkpoint Inhibitor Toxicity

• Grade 2: 0.5-1 mg/kg/day prednisone orally or methylprednisolone IV 3
• Grade 3-4: 1-2 mg/kg/day prednisone or equivalent methylprednisolone 3
• Escalation: If no improvement in 2-3 days, increase to 2 mg/kg/day 3

Nephrotic Syndrome (Pediatric)

• Initial episode: 60 mg/m² or 2 mg/kg/day prednisone (maximum 60 mg/day) for 4-6 weeks 3
• Alternate-day maintenance: 40 mg/m² or 1.5 mg/kg (maximum 40 mg) on alternate days 3

Crohn's Disease

• Active disease: 0.5-0.75 mg/kg/day prednisone (maximum 60 mg/day) 3
• Oral methylprednisolone: 48 mg/day tapered weekly to 32 mg, 24 mg, then 12 mg over 6 weeks 3

Recurrent Pericarditis

• Starting dose: 0.25-0.5 mg/kg/day prednisone 3
• Equivalent: 25 mg prednisone = 20 mg methylprednisolone 3

Critical Tapering Thresholds

The most critical threshold for recurrence and adverse effects is 10-15 mg/day prednisone, requiring extremely slow tapering at this level. 3

Tapering Schedule for Prednisone

• >50 mg/day: Decrease by 10 mg every 1-2 weeks 3
• 50-25 mg/day: Decrease by 5-10 mg every 1-2 weeks 3
• 25-15 mg/day: Decrease by 2.5 mg every 2-4 weeks 3
• <15 mg/day: Decrease by 1.25-2.5 mg every 2-6 weeks 3
• After long-term therapy: Taper to 10 mg/day within 4-8 weeks, then reduce by 1 mg every 4 weeks 5

Immune-Related Adverse Events

• Standard taper: 4-6 week steroid taper once improved to ≤grade 1 3
• Taper only when: Patient is asymptomatic AND C-reactive protein is normal 3

Critical Safety Considerations

Doses higher than 0.75 mg/kg/day do not provide additional benefit and are associated with significantly increased mortality. 5

Adverse Effects and Monitoring

• Common side effects: Cushing syndrome, infection, diabetes, osteoporosis, cataracts, hypertension, increased mortality 3
• Never use as maintenance therapy: Corticosteroids should never be used for long-term maintenance due to significant morbidity and mortality 3, 5
• Osteoporosis prevention: Start calcium 1,200-1,500 mg/day plus vitamin D 800-1,000 IU/day with all corticosteroid therapy 3
• Bisphosphonates: Recommended for men ≥50 years and postmenopausal women on ≥5-7.5 mg/day prednisone long-term 3
• PCP prophylaxis: Required if >3 weeks of immunosuppression expected (>30 mg/day prednisone or equivalent) 3
• GI prophylaxis: Proton pump inhibitor for all patients on systemic corticosteroids 3

Common Pitfalls to Avoid

• Abrupt discontinuation: Always taper gradually after long-term therapy; never stop abruptly 1, 2
• Excessive initial dosing: Starting doses >60 mg/day prednisone rarely indicated and increase toxicity 3, 5
• Prolonged high-dose therapy: Maintain high doses only briefly, then taper aggressively to <15 mg/day 3, 5
• Evening administration: Avoid dosing after 9 AM to minimize HPA axis suppression 1
• Forgetting conversion: Always remember 4 mg methylprednisolone = 5 mg prednisone when switching formulations 2