Prednisone Dosing Range
Prednisone dosing ranges from 5-60 mg/day for initial therapy depending on disease severity, with most conditions responding to 0.5-2 mg/kg/day (maximum 60 mg/day), and long-term maintenance typically requiring 5-10 mg/day or less. 1
Initial Dosing by Disease Severity
The FDA label establishes that initial dosing varies from 5-60 mg per day depending on the specific disease entity and severity, with lower doses for less severe conditions and higher initial doses for selected patients with more severe disease 1.
Weight-based dosing is the standard approach for most conditions:
- Severe disease: 1-2 mg/kg/day (maximum 60 mg/day) 2, 3
- Moderate disease: 0.5-1 mg/kg/day 3
- Mild disease: 0.3-0.5 mg/kg/day 3
For an average 70 kg adult, this translates to approximately 20-140 mg/day for severe disease, though the practical maximum is typically capped at 60 mg/day for most conditions 3, 4.
Dose Categories by Magnitude
The American College of Rheumatology defines corticosteroid dosing categories that help frame clinical decision-making 4:
- Low-dose: <7.5 mg/day
- Medium-dose: 7.5-30 mg/day
- High-dose: >30 mg/day
Maintenance Dosing
After achieving disease control, the goal is to taper to the lowest effective dose, typically 5-10 mg/day or less. 2, 5
For autoimmune hepatitis specifically, the recommended maintenance is prednisolone 5-10 mg/day for at least 2 years 5. In rheumatoid arthritis, long-term maintenance doses of less than 5 mg/day have proven effective, with mean maintenance doses of 4-6 mg/day in clinical practice 6, 7, 8.
Tapering Strategy
Tapering should be gradual to avoid adrenal insufficiency and disease flare:
- From 20 mg/day: reduce by 5 mg weekly until reaching 10 mg/day 2
- From 10 mg/day: reduce by 2.5 mg weekly until reaching 5 mg/day 2
- Below 10 mg/day: taper by 1 mg every 4 weeks 4
The FDA emphasizes that if long-term therapy is to be stopped, withdrawal should be gradual rather than abrupt 1.
Pediatric Dosing
Children require weight-based or body surface area-based dosing:
- Initial: 1-2 mg/kg/day (maximum 60 mg/day) for 2 weeks 2
- Maintenance: taper over 6-8 weeks to 0.1-0.2 mg/kg/day or 5 mg/day 2
- For nephrotic syndrome: 60 mg/m² or 2 mg/kg/day (maximum 60 mg/day) 3, 4
In significantly overweight children, dosing should be based on ideal body weight with consideration of a maximum dose of 80 mg daily 4.
Administration Timing
Prednisone should be administered in the morning prior to 9 AM as a single daily dose to minimize suppression of the hypothalamic-pituitary-adrenal axis, since maximal adrenal cortex activity occurs between 2 AM and 8 AM 1. When large doses are required, antacids should be given between meals to prevent peptic ulcers 1.
Critical Safety Thresholds
Adrenal suppression risk occurs with any dose >7.5 mg/day for >3 weeks, requiring stress-dose coverage during illness or surgery 4. Patients on chronic medium/high-dose therapy require a pragmatic increase in dosage for 3 days during stress or a switch to IV hydrocortisone 4.
Common Pitfalls
The most significant pitfall is using higher doses than necessary. Historical data shows mean initial prednisone doses declined from 10.3 mg/day in 1980-1984 to 3.6 mg/day in 2000-2004, with similar or better clinical outcomes 8. Doses ≥5 mg/day are associated with dose-dependent adverse events including fractures, infections, and GI bleeding 9, while doses <5 mg/day appear to have an acceptable safety profile for long-term use 6, 8.
Another critical error is abrupt discontinuation—the FDA explicitly warns against stopping without gradual tapering 1.
Long-Term Monitoring Requirements
Patients on long-term corticosteroid treatment require 2, 4:
- Baseline and annual bone mineral densitometry of lumbar spine and hip
- Calcium and vitamin D supplementation
- DEXA scanning at 1-2 year intervals