What is the appropriate treatment for an adult or adolescent patient with moderate hives (urticaria) and no contraindications, using oral prednisone (corticosteroid) 5mg?

Oral Prednisone for Moderate Hives

For moderate acute urticaria, use prednisolone 50 mg daily for 3 days (not a 21-tablet taper pack), and only after confirming inadequate response to high-dose second-generation antihistamines. 1, 2

First-Line Treatment: Antihistamines Before Steroids

• Start with second-generation H1 antihistamines (cetirizine, loratadine, fexofenadine, or levocetirizine) at standard doses for 2-4 weeks, as more than 40% of patients respond to antihistamines alone 1, 2
• If inadequate response after 2-4 weeks, increase the antihistamine dose up to 4 times the standard dose before adding corticosteroids 1, 2
• Never use corticosteroids as first-line treatment when antihistamines are sufficient 1, 2

Appropriate Corticosteroid Regimen

• The guideline-recommended regimen is prednisolone 50 mg orally daily for 3 days, not a 21-tablet taper pack 1, 2
• Lower doses are frequently effective and should be considered to minimize corticosteroid exposure 1, 2
• A 5mg × 21-tablet pack (typically a 12-14 day taper) exceeds the recommended 3-10 day maximum duration and increases risk of cumulative toxicity 1, 2
• Recent systematic reviews show that adding corticosteroids to antihistamines did not improve symptoms in 2 out of 3 RCTs, questioning their routine use 3

Evidence Quality and Strength

The British Journal of Dermatology guidelines (2007) recommend restricting oral corticosteroids to short courses for severe acute urticaria, with strength of recommendation C (poor evidence quality) 4. Despite limited evidence, the American College of Allergy, Asthma, and Immunology still recommends prednisolone 50 mg daily for 3 days based on clinical experience and need for rapid symptom control in severe cases 1. A 2010 retrospective study showed that a single short course of prednisone 25 mg/day for 3 days induced remission in nearly 50% of antihistamine-resistant chronic urticaria patients 5.

Administration Guidelines

• Administer prednisone in the morning prior to 9 AM to minimize adrenal suppression, as maximal adrenal cortex activity occurs between 2 AM and 8 AM 6
• Take with food or milk to reduce gastric irritation 6
• Consider antacids between meals when using higher doses to prevent peptic ulcers 6

Critical Pitfalls to Avoid

• The most critical error is using a prolonged taper (like a 21-tablet pack) when a 3-day course is guideline-recommended 1, 2
• Never continue corticosteroids beyond 3-10 days due to cumulative toxicity including osteoporosis, diabetes, hypertension, and adrenal suppression 1, 2, 6
• Do not use chronic corticosteroids for chronic spontaneous urticaria, as this leads to cumulative toxicity without sustained benefit (Strength of recommendation A) 4, 1
• Avoid abrupt withdrawal after prolonged therapy; gradual tapering is essential to prevent adrenal insufficiency 6

When Corticosteroids Are Appropriate

• Reserve corticosteroids for severe acute urticaria affecting >30% body surface area or causing significant functional impairment 7
• Use only after documented failure of antihistamine dose escalation up to 4 times standard dose 1, 2
• Consider for severe acute exacerbations with angioedema affecting the mouth or throat 4

Alternative Approaches for Refractory Cases

• Add H2 antihistamines (ranitidine 50 mg IV or famotidine) to H1 antihistamines, which showed superior efficacy in 2 out of 5 studies 3
• Consider leukotriene receptor antagonists (montelukast) for antihistamine-refractory cases 2
• For chronic autoimmune urticaria unresponsive to antihistamines, omalizumab 300 mg subcutaneously every 4 weeks is preferred over prolonged corticosteroids 1, 2
• Cyclosporine 4 mg/kg daily for up to 2 months is effective in approximately two-thirds of severe autoimmune urticaria cases 4, 1

Monitoring Requirements

• Monitor blood pressure, glucose, and weight during corticosteroid therapy, even for short courses 6
• Assess for signs of infection, as corticosteroids mask inflammatory responses 6
• If therapy extends beyond 6 weeks (which should be avoided), monitor intraocular pressure 6
• Consider calcium and vitamin D supplementation if corticosteroid therapy exceeding 3 months is anticipated 6