What is a suitable moderate steroid to use?

Moderate-Potency Steroid Recommendations

For systemic corticosteroid therapy requiring moderate dosing, prednisolone 40 mg daily (or prednisone 0.5-0.75 mg/kg/day) represents the optimal moderate-dose regimen, balancing efficacy with an acceptable adverse event profile across multiple inflammatory conditions. 1

Dosing Framework by Clinical Context

Inflammatory Bowel Disease (Moderate Activity)

• Prednisolone 40 mg daily is optimal for outpatient management of moderate ulcerative colitis, with evidence showing 77% remission rates within 2 weeks 1
• Doses of 60 mg/day produce significantly more adverse events without added benefit 1
• For moderate Crohn's disease, prednisone 40-60 mg/day is recommended after budesonide failure 1
• Taper over 6-8 weeks once control is achieved, reducing by one-third to one-quarter at fortnightly intervals down to 15 mg daily, then by 2.5 mg decrements 1

Dermatologic Conditions (Moderate Disease)

• For moderate bullous pemphigoid, prednisolone 0.5 mg/kg/day (approximately 35 mg for a 70 kg patient) achieves disease control in 68.8% of patients by day 21 2
• This dose demonstrates superior safety compared to 1 mg/kg/day regimens while maintaining efficacy 1
• For localized disease, prednisolone 0.3 mg/kg/day may suffice 1

Rheumatologic Conditions

• Low-dose corticosteroids (≤10 mg/day prednisone) are considered appropriate for rheumatoid arthritis as bridge therapy or NSAID substitution 3
• For polymyalgia rheumatica, initial doses of 15 mg daily oral prednisolone achieve 60.6% remission rates 4

Key Dosing Principles

Starting Dose Selection

• Mild disease: 0.3-0.5 mg/kg/day prednisolone 1
• Moderate disease: 0.5 mg/kg/day or 40 mg daily 1, 2
• Severe disease: 0.75-1.0 mg/kg/day (up to 60 mg daily maximum) 1

Tapering Strategy

• Maintain initial dose until disease control (typically 2-4 weeks) 1
• Reduce by one-third to one-quarter at fortnightly intervals down to 15 mg daily 1
• Below 15 mg, taper by 2.5 mg decrements 1
• Below 10 mg, reduce by 1 mg monthly 1
• Doses below 15 mg/day are ineffective for active inflammatory disease 1

Alternative Moderate-Potency Options

Topical Alternatives

• Budesonide 9 mg/day orally represents a moderate-potency topically-acting alternative for inflammatory bowel disease, with reduced systemic effects but slightly lower efficacy than prednisolone 1
• For ulcerative colitis, budesonide MMX 9 mg/day achieves 17.7% combined clinical and endoscopic remission versus 6.2% for placebo 1

Route Considerations

• Oral prednisolone is preferred over intramuscular methylprednisolone for most moderate disease due to ease of dose adjustment 4
• Single daily dosing causes less adrenal suppression than split dosing 1

Critical Safety Considerations

Adverse Event Profile

• At 40 mg/day, adverse events are significantly lower than at 60 mg/day without sacrificing efficacy 1
• Common short-term effects (affecting ~50% of patients): acne, edema, sleep disturbance, mood changes, glucose intolerance, dyspepsia 1
• Serious complications increase with cumulative dose: fractures, weight gain, hypertension, cataracts 1, 4

Contraindications to Moderate-Dose Steroids

• Poorly controlled diabetes 1
• History of steroid-induced psychosis or severe depression 1
• Severe osteoporosis with pathologic fractures 1
• History of avascular necrosis 1

Mandatory Prophylaxis

• All patients starting corticosteroids require calcium and vitamin D supplementation 1
• Bisphosphonates are recommended for postmenopausal women and men over 50 expected to take prednisolone ≥7.5 mg daily for ≥3 months 1
• Gastric protection with proton pump inhibitors should be considered 1

Clinical Pitfalls to Avoid

Dosing Errors

• Too rapid tapering (reducing before 2-4 weeks) associates with early relapse 1
• Doses below 15 mg/day are ineffective for treating active disease 1
• Increasing beyond 60 mg/day provides no additional benefit and significantly increases toxicity 1

Duration Mistakes

• Steroids should never be used as maintenance therapy in inflammatory bowel disease 1
• Patients requiring ≥2 courses within a calendar year need steroid-sparing agents 1
• Disease relapse as dose reduces below 15 mg indicates need for alternative therapy 1

Monitoring Failures

• Assess symptomatic response at 2-4 weeks to determine need for therapy modification 1
• Patients with no improvement or worsening by 2-4 weeks require treatment escalation 1

Dose Equivalencies for Reference

For 15 mg prednisolone base (moderate dose): 5

• Prednisone: 15 mg
• Methylprednisolone: 12 mg
• Hydrocortisone: 60 mg
• Dexamethasone: 2.25 mg
• Betamethasone: 2.25 mg

These equivalencies apply only to oral or intravenous routes; intramuscular or intra-articular administration significantly alters relative potencies 5