What is the recommended dose of prednisone (corticosteroid) for very inflamed tonsils?

Prednisone for Very Inflamed Tonsils

For acute tonsillitis with severe inflammation, a short course of prednisone 30-40 mg daily (or 0.5-1.0 mg/kg daily, maximum 80 mg) for 1-2 weeks with tapering is recommended based on extrapolation from guidelines for similar inflammatory conditions of the upper airway. 1

Evidence Base and Rationale

The available evidence does not provide direct guideline recommendations specifically for prednisone dosing in acute tonsillitis. However, several high-quality guidelines address corticosteroid use for similar inflammatory conditions of the upper respiratory tract:

Dosing Recommendations from Related Conditions

For severe inflammatory conditions of the upper airway and mediastinum:

• Prednisone 0.5-1.0 mg/kg daily (maximum 80 mg daily) in tapering doses over 1-2 weeks is recommended for severe cases with obstruction or compression 1
• For postinfectious severe inflammation causing significant symptoms, 30-40 mg prednisone daily for a short, finite period has been used successfully 1

Supporting Research Evidence

Single high-dose intravenous steroid administration has demonstrated benefit in peritonsillar abscess:

• A randomized controlled trial showed that single-dose IV steroid plus antibiotics significantly reduced hospitalization time, throat pain, fever, and trismus compared to antibiotics alone (p < 0.01) 2
• This suggests corticosteroids have anti-inflammatory efficacy in severe tonsillar inflammation

However, postoperative oral steroids after tonsillectomy showed no benefit:

• A randomized, double-blind trial of 5-day oral prednisolone after tonsillectomy found no significant difference in pain, nausea, return to normal diet, or activity compared to placebo 3
• This contrasts with proven benefit of single intraoperative dose of dexamethasone 0.5 mg/kg (range 0.15-1.0 mg/kg) for reducing postoperative pain and nausea 1

Practical Dosing Algorithm

For Adults with Severe Tonsillitis:

• Start with prednisone 40 mg daily (or 0.5-1.0 mg/kg, max 80 mg) 1
• Continue for 3-5 days at full dose
• Taper over 1-2 weeks total duration 1
• Example taper: 40 mg × 3 days → 30 mg × 3 days → 20 mg × 3 days → 10 mg × 3 days → 5 mg × 2 days → stop

For Children with Severe Tonsillitis:

• Use 0.5-1.0 mg/kg daily (maximum 80 mg) 1
• Same tapering schedule over 1-2 weeks

Critical Caveats and Contraindications

Exclude patients with:

• Endocrine disorders already receiving exogenous steroids 1
• Diabetes or conditions where steroid administration may interfere with glucose-insulin regulation 1
• Suspected bacterial infection without concurrent antibiotic coverage 1

Always combine with appropriate antibiotic therapy:

• If bacterial tonsillitis is suspected, prescribe phenoxymethylpenicillin (Penicillin V) 500 mg twice daily for 10 days 4, 5
• Corticosteroids should never be used as monotherapy for infectious tonsillitis 1

Monitoring During Treatment

Watch for:

• Lack of improvement within 5-7 days suggests alternative diagnosis or complications 1
• Signs of peritonsillar abscess formation (severe unilateral pain, trismus, uvular deviation) requiring drainage 2
• Adrenal insufficiency symptoms if tapering too rapidly after courses >3 weeks 6

Common Pitfalls to Avoid

Do not:

• Use prolonged courses without tapering (>3 weeks requires formal taper to prevent adrenal insufficiency) 6
• Prescribe steroids without ruling out bacterial infection requiring antibiotics 1
• Continue steroids beyond 2 weeks for simple tonsillitis 1
• Use postoperative oral steroids after tonsillectomy (no proven benefit) 3

Do:

• Limit to severe cases where inflammation significantly impairs swallowing, breathing, or quality of life 1
• Consider single-dose IV dexamethasone as alternative for acute severe presentations 1, 2
• Reassess if symptoms persist beyond expected timeframe 1