Prednisone Dosing for Sudden Sensorineural Hearing Loss
Administer prednisone at 1 mg/kg/day (maximum 60 mg daily) as a single morning dose for 7-14 days, followed by a taper over a similar time period. 1
Dosing Regimen
- Prednisone: 1 mg/kg/day with a usual maximum of 60 mg daily 1, 2
- Give as a single daily dose (do not divide) 1, 2
- Continue full dose for 7-14 days 1, 2
- Taper over a similar time period (7-14 days) after completing full-dose treatment 1, 2
Alternative Equivalent Corticosteroids
If prednisone is not available or tolerated, use these equivalent doses:
- Methylprednisolone: 48 mg/day (5 times more potent than hydrocortisone) 1, 2
- Dexamethasone: 10 mg/day (25 times more potent than hydrocortisone) 1, 3
These recommendations come from the 2019 American Academy of Otolaryngology-Head and Neck Surgery clinical practice guideline, which provides the most authoritative guidance on this topic. 1
Critical Timing Considerations
- Begin treatment immediately, ideally within the first 14 days of symptom onset 1, 2
- The greatest spontaneous improvement and treatment benefit occur in the first 2 weeks 2, 4
- Some benefit has been reported up to 6 weeks post-onset, but efficacy diminishes significantly after 2 weeks 1, 2
Intratympanic Steroids as Alternative or Salvage
For patients who cannot tolerate systemic steroids (diabetes, hypertension, glaucoma, peptic ulcer disease, psychiatric reactions to steroids), intratympanic injection is not inferior in efficacy: 1
- Dexamethasone: 24 mg/mL (compounded) or 10 mg/mL (stock) 1, 2
- Methylprednisolone: 40 mg/mL or 30 mg/mL 1, 2
- Inject 0.4-0.8 mL into middle ear space 1
- Administer up to 4 injections over a 2-week period 1
- Keep head in otologic position (affected ear up) for 15-30 minutes after injection 1
A 2011 randomized trial in JAMA demonstrated that intratympanic methylprednisolone was non-inferior to oral prednisone, with PTA improvement of 28.7 dB vs 30.7 dB respectively. 5 This supports intratympanic therapy as a legitimate first-line option when systemic steroids are contraindicated.
Monitoring Requirements
- Audiogram before treatment, at completion, and at delayed intervals 1, 2
- Monitor for hyperglycemia and hypertension in susceptible patients 1, 2
- For intratympanic therapy, inspect tympanic membrane to ensure healing 1
Evidence Quality and Nuances
The guideline acknowledges that evidence supporting systemic steroids for sudden sensorineural hearing loss is equivocal, with shared decision-making playing a large role. 1 However, most serious side effects occur with chronic use, and adverse events are rare and manageable for the short 10-14 day course. 1, 2
A 2024 systematic review found mixed results when comparing high-dose to standard-dose regimens, with overall low-quality evidence and moderate risk of bias. 6 This reinforces the guideline's recommendation to stick with the established 1 mg/kg/day dosing rather than pursuing higher doses.
A 2003 retrospective study showed significant improvement (p<0.01) in severe-to-profound cases treated with prednisone 60 mg with taper versus untreated cases. 7
Common Pitfalls to Avoid
- Underdosing: Ensure the full 1 mg/kg/day is given, not a standard methylprednisolone dose pack which provides significantly less than the recommended total dose 2, 4
- Delayed treatment: Initiate therapy immediately upon diagnosis, as efficacy diminishes after 2 weeks 1, 2
- Divided dosing: Give prednisone as a single morning dose to minimize HPA axis suppression 1, 2
- Inadequate taper: Taper over 7-14 days after completing full-dose treatment 1, 2