What is the recommended dosing for prednisone (corticosteroid) in patients with various medical conditions, such as asthma or rheumatoid arthritis, considering factors like diabetes, hypertension, and osteoporosis?

Prednisone Dosing Recommendations

General Dosing Principles

Prednisone dosing must be individualized based on the specific disease being treated, with initial doses ranging from 5-60 mg/day, but the key principle is to use the lowest effective dose for the shortest duration necessary. 1

Disease-Specific Initial Dosing

Polymyalgia Rheumatica (PMR):

• Start with 12.5-25 mg/day oral prednisone 2
• Use the lower end (12.5 mg/day) in patients with diabetes, osteoporosis, glaucoma, or hypertension to minimize glucocorticoid-related adverse effects 2
• Use the higher end (25 mg/day) in patients with high relapse risk and low risk of adverse events 2
• Taper to 10 mg/day within 4-8 weeks, then reduce by 1 mg every 4 weeks until discontinuation 3

Rheumatoid Arthritis (RA):

• Use ≤10 mg/day prednisone for chronic management—doses above this increase harm without additional benefit 4, 5
• 5 mg twice daily may be more effective than 10 mg once daily for controlling inflammation throughout the day 5, 6
• Doses <5 mg/day are effective and safe for long-term use in many RA patients 7, 8
• Never exceed 15 mg/day due to increased infection risk 4
• Strongly avoid doses >30 mg/day due to incontrovertible evidence of harm 4

Autoimmune Hepatitis:

• Start with prednisone 30 mg/day plus azathioprine 50 mg/day 2
• Taper prednisone to 10 mg/day over 2-3 months as transaminases normalize 2
• Once azathioprine is established (2-3 months), can reduce prednisone by 5 mg every week until reaching 10 mg/day 3
• Then taper by 2.5 mg every 2-4 weeks once at 10 mg/day 3

Multiple Sclerosis (Acute Exacerbations):

• 200 mg/day for 1 week, followed by 80 mg every other day for 1 month 1

Critical Timing and Administration

Single daily dosing in the morning (before 9 AM) is strongly preferred to minimize adrenal suppression, as this aligns with the body's natural cortisol peak between 2-8 AM 2, 3, 1

Exception: Divided doses may be used for prominent night pain when tapering below 5 mg/day 2, 3

Tapering Strategies Based on Current Dose

For doses >30 mg/day:

• Reduce by 10 mg every 2 weeks until reaching 30 mg/day 3
• Then reduce by 5 mg every 2 weeks until reaching 20 mg/day 3

For doses 10-30 mg/day:

• Taper by 5 mg every week until reaching 10 mg/day 3
• Then slow to 2.5 mg/week until reaching 5 mg/day 3

For doses 5-10 mg/day:

• Taper by 1 mg every 4 weeks 2, 3
• Alternative: Use alternate-day dosing (e.g., 10/7.5 mg on alternating days) to achieve gradual reductions 3

For doses <5 mg/day:

• Taper by 1 mg every 4 weeks until discontinuation 3
• Never taper faster than 1 mg per month to minimize relapse risk 4

Managing Comorbidities

Diabetes:

• Use lower initial doses (12.5 mg/day for PMR) 2
• Monitor blood glucose closely during therapy 2, 1
• Consider intramuscular methylprednisolone as alternative to reduce cumulative exposure 2

Hypertension:

• Use lower initial doses 2
• Monitor blood pressure regularly 2
• Avoid sodium retention by dietary salt restriction 1
• Consider IM methylprednisolone in difficult-to-control hypertension 2

Osteoporosis:

• Mandatory calcium 800-1,000 mg/day and vitamin D 400-800 units/day for all patients on prednisone >7.5 mg/day for >3 months 2, 4, 5
• Bisphosphonate therapy should be initiated based on bone mineral density and risk factors 2
• Use lowest effective dose and consider IM methylprednisolone to reduce cumulative exposure 2, 1

Glaucoma:

• Use lower initial doses 2
• Monitor intraocular pressure if therapy continues >6 weeks 1

Alternative Route: Intramuscular Methylprednisolone

Consider IM methylprednisolone 120 mg every 3 weeks as alternative to oral prednisone in patients with: 2

• Difficult-to-control diabetes
• Difficult-to-control hypertension
• Severe osteoporosis
• Glaucoma
• Desire for lower cumulative glucocorticoid exposure

Dosing schedule: 120 mg every 3 weeks until week 9, then 100 mg at week 12, then monthly with 20 mg reductions every 12 weeks until week 48, then 20 mg reductions every 16 weeks until discontinuation 2

Essential Preventive Measures for All Patients

Before initiating therapy:

• Assess for hypertension, diabetes, peptic ulcer, recent fractures, cataracts, glaucoma, infections, and dyslipidemia 2
• Document baseline bone mineral density if therapy >3 months anticipated 2

During therapy:

• Monitor body weight, blood pressure, serum lipids, blood/urine glucose 2
• Gastric protection with proton pump inhibitors or misoprostol if taking concurrent NSAIDs 2

For therapy >1 month:

• Adequate glucocorticoid replacement during surgery to prevent adrenal insufficiency 2
• Patient education on stress dosing for acute illness 3

Managing Relapse During Tapering

If disease flare occurs:

• Immediately return to the pre-relapse dose 3
• Maintain for 4-8 weeks until disease control re-established 3
• Then attempt slower taper 3
• Consider adding steroid-sparing agents (methotrexate, azathioprine) if multiple relapses occur 2, 3

Critical Pitfalls to Avoid

Never stop prednisone abruptly after >3 weeks of therapy—risk of adrenal insufficiency 3, 1

Never taper faster than 1 mg per month when below 10 mg/day—increases relapse risk 4

Never use chronic doses >10 mg/day for RA—increases harm without additional benefit 4, 5

Never fail to provide calcium and vitamin D supplementation for patients on >7.5 mg/day for >3 months 2, 4

Never ignore stress dosing requirements—patients require supplemental glucocorticoids during acute illness or surgery for up to 12 months after discontinuation 3, 1