What is the recommended steroid dose with equivalent conversion for a general adult patient?

Steroid Dose Equivalency and Conversion

For general adult patients, prednisone 5 mg is equivalent to hydrocortisone 20 mg and methylprednisolone 4 mg, with standard dosing ranging from 0.3-2 mg/kg/day depending on disease severity. 1, 2

Standard Equivalent Conversions

• Prednisone 5 mg = Hydrocortisone 20 mg = Methylprednisolone 4 mg 1
• These conversions are critical for perioperative management and when switching between formulations 1

Dose Categories by Intensity

The American College of Rheumatology defines three key dosing thresholds 2:

• Low-dose: <7.5 mg/day prednisone 2
• Medium-dose: 7.5-30 mg/day prednisone 2
• High-dose: >30 mg/day prednisone 2

Very high-dose glucocorticoid therapy is defined as ≥30 mg/day prednisone for ≥30 days or cumulative dose ≥5 g over 1 year, which carries significantly increased fracture risk (vertebral fracture relative risk 14, hip fracture relative risk 3) 1

Initial Dosing by Disease Severity

For severe disease: 1-2 mg/kg/day (maximum 60 mg/day) 2, 3

For moderate disease: 0.5-1 mg/kg/day 2, 3

For mild disease: 0.3-0.5 mg/kg/day 2, 3

For a 70 kg patient, this translates to:

• Severe: 70-140 mg/day (capped at 60 mg/day maximum)
• Moderate: 35-70 mg/day
• Mild: 21-35 mg/day

Maintenance Dosing Strategy

After achieving disease control, taper to the lowest effective dose, typically 5-10 mg/day or less 2

The tapering protocol should follow this algorithm 2:

• Above 10 mg/day: Reduce by 5 mg weekly until reaching 10 mg/day
• Between 5-10 mg/day: Reduce by 2.5 mg weekly until reaching 5 mg/day
• Below 10 mg/day: Reduce by 1 mg every 4 weeks

This gradual approach minimizes adrenal insufficiency risk and disease flare 2

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 2

Glucocorticoid-induced osteoporosis (GIOP) prevention is mandatory for doses ≥2.5 mg/day for ≥3 months 1:

• Optimize calcium intake: 1,000-1,200 mg/day 1
• Optimize vitamin D intake: 600-800 IU/day (target serum level ≥20 ng/ml) 1
• Baseline and annual bone mineral density testing of lumbar spine and hip 2
• Consider bisphosphonate therapy for moderate-to-high fracture risk patients 1

Perioperative Steroid Management

For patients on chronic steroids undergoing surgery, continue equivalent IV dosing perioperatively 1:

• Convert oral prednisone to IV hydrocortisone using 5 mg prednisone = 20 mg hydrocortisone 1
• No evidence supports increasing steroid dosage to cover surgical stress 1
• Anaesthetists typically give single preoperative dose (e.g., dexamethasone 4 mg IV/IM) for patients taking >5 mg prednisone 1

Preoperative optimization for elective surgery: Steroids should be stopped or minimized wherever possible, as doses ≥20 mg prednisolone are associated with increased infection risk and anastomotic complications 1

Special Population Considerations

For immune checkpoint inhibitor toxicities 1:

• Grade 2: Prednisone 0.5-1 mg/kg/day
• Grade 3-4: Prednisone 1-2 mg/kg/day (or equivalent methylprednisolone)
• Add PCP prophylaxis if >3 weeks of immunosuppression expected (>30 mg prednisone/day)
• Add proton pump inhibitor for GI prophylaxis

For bullous pemphigoid 1, 3:

• Severe disease: 0.75-1 mg/kg/day
• Moderate disease: 0.5 mg/kg/day
• Mild/localized disease: 0.3 mg/kg/day
• Doses >52.5 mg daily (for 70 kg patient) show no additional benefit but increased mortality 1

Common Pitfalls to Avoid

Do not abruptly discontinue steroids - patients should be warned that prolonged use causes adrenal insufficiency and dependence, requiring gradual taper 4

Do not use uniform dosing without weight adjustment - while many older studies used fixed doses (40-80 mg daily), weight-based dosing (mg/kg) is more appropriate for optimizing efficacy while minimizing toxicity 1, 2

Do not neglect osteoporosis prevention - interventions should be initiated in any patient receiving ≥5 mg prednisone for ≥3 months, including calcium/vitamin D supplementation, lifestyle modifications, and bisphosphonates for those with low bone mineral density 1, 4

Do not continue high doses longer than necessary - the goal is always to taper to the minimum effective dose, as adverse effects are dose- and duration-dependent 4, 5