What is the proper usage and dosage of Prednisone (corticosteroid) for various medical conditions?

Prednisone Dosing and Usage

Prednisone dosing must be individualized based on the specific disease being treated, with initial doses ranging from 5-60 mg daily for most conditions, though certain severe diseases require higher doses up to 200 mg daily. 1

General Dosing Principles

Administration Timing and Food

• Administer prednisone in the morning prior to 9 AM to align with maximal adrenal cortex activity (2 AM to 8 AM) and minimize adrenocortical suppression 1
• Take before, during, or immediately after meals to reduce gastric irritation 1
• When using multiple daily doses, distribute evenly throughout the day 1

Initial Dosing by Condition

Autoimmune Hepatitis:

• Treatment failure cases: 60 mg daily as monotherapy, OR 30 mg daily combined with azathioprine 150 mg daily for at least 1 month 2
• For azathioprine-intolerant patients: 60 mg/day initially, reducing over 4 weeks to 20 mg/day 3
• Taper by 10 mg prednisone monthly as improvement occurs until reaching standard doses 2

Nephrotic Syndrome/FSGS:

• 1 mg/kg daily (maximum 80 mg) OR 2 mg/kg alternate-day (maximum 120 mg) 4
• Note: 2 mg/kg dosing is NOT equivalent to 60 mg/m² BSA dosing in children <30 kg, with 2 mg/kg providing approximately 85% of the BSA-calculated dose 5

Multiple Sclerosis Acute Exacerbations:

• 200 mg daily for 1 week, followed by 80 mg every other day for 1 month 1
• High compliance rates (94.3%) reported with equivalent oral dosing of 1,250 mg daily 6

Sudden Hearing Loss:

• 1 mg/kg/day (usual maximum 60 mg/day) as single morning dose for 7-14 days, then tapered over similar period 3

Idiopathic Pulmonary Fibrosis:

• 40-100 mg daily for 2-4 months, then gradual taper 2
• Assess response at 3 months using objective parameters (dyspnea scores, pulmonary function tests, imaging) 2
• Maintenance therapy: 15-20 mg every other day for responders, potentially indefinitely 2

Rheumatoid Arthritis (Long-term Low-dose):

• <5 mg/day for chronic management appears effective with acceptable safety profile 7
• Lower doses (mean 3.6 mg/day) show similar efficacy to higher doses when used long-term 7

Duchenne Muscular Dystrophy:

• 0.75 mg/kg daily provides maximal benefit with dose-response evident at 3 months 8
• 0.3 mg/kg daily shows benefit with fewer side effects (only weight gain vs. cushingoid features at higher dose) 8

Tapering Strategy

Standard Taper

• Reduce to 10 mg/day within 4-8 weeks, then taper by 1 mg every 4 weeks to minimize adrenal insufficiency risk 3
• For autoimmune hepatitis remission: gradual withdrawal over 6-week period with monitoring every 3 weeks 2
• Never abruptly discontinue after long-term therapy 1

Incomplete Response Management

• Reduce by 2.5 mg/month to lowest dose (typically 10 mg daily) that prevents worsening 2

Monitoring Requirements

Laboratory Monitoring

• Adrenal suppression anticipated with >7.5 mg daily for >3 weeks 3
• Monitor AST/ALT every 3 weeks during and for 3 months after withdrawal (autoimmune hepatitis) 2
• Assess response at 3 months using objective clinical parameters, not subjective improvement alone 2

Bone Health

• Calcium and vitamin D supplementation required for all patients on long-term therapy 3
• DEXA scanning at 1-2 year intervals while on steroids 3

Alternate Day Therapy

Alternate day dosing (twice the daily dose every other morning) minimizes pituitary-adrenal suppression, Cushingoid features, and growth suppression in children while maintaining therapeutic benefit 1

Critical Safety Considerations

Side Effects Requiring Dose Adjustment

• Intolerable cosmetic changes, symptomatic osteopenia, emotional instability, poorly controlled hypertension, brittle diabetes, or progressive cytopenia warrant dose reduction or discontinuation 2
• Common side effects include insomnia, mood changes, increased appetite, bruising, and skin thinning 7, 6

Pregnancy Considerations

• Corticosteroid side effects must be reviewed before treatment initiation 2
• Resume standard therapy 2 weeks before anticipated delivery to prevent postpartum exacerbation (autoimmune hepatitis) 2

Equivalence Information

Prednisone and prednisolone are pharmacologically equivalent at the same dosage, with choice depending on geographic availability (prednisone in US, prednisolone in Europe) 4

Conversion: Prednisone 60 mg = Methylprednisolone 48 mg = Dexamethasone 10 mg 3