What are the appropriate dosages and usage guidelines for prednisolone (corticosteroid) in patients with various medical conditions, considering factors such as age, weight, and medical history?

Prednisolone Dosing and Usage Guidelines

Prednisolone dosing must be tailored to the specific medical condition being treated, with initial doses ranging from 5-60 mg daily for adults and 0.14-2 mg/kg/day for children, always using the lowest effective dose to minimize adverse effects while maintaining disease control. 1

Adult Dosing by Condition

Asthma Exacerbations

• Administer 40-60 mg daily as a single morning dose or in 2 divided doses for 3-10 days 2, 3
• No tapering required for courses ≤10 days if patient is on concurrent inhaled corticosteroids 3
• Continue until symptoms resolve or peak expiratory flow reaches 70% of predicted 3

Autoimmune/Inflammatory Conditions

• Initial dose: 60 mg daily for monotherapy or 30 mg daily when combined with azathioprine 50 mg daily 4
• Tapering schedule: Reduce by 10 mg weekly until reaching 20 mg daily, then by 2.5-5 mg weekly to 10 mg daily, then by 1 mg monthly to reach minimum effective dose 4
• Goal maintenance dose: 5-10 mg daily or less, with 87% of patients maintainable on ≤10 mg daily 4

Tuberculous Pericarditis

• 60 mg daily for 4 weeks, then 30 mg daily for 4 weeks, then 15 mg daily for 2 weeks, then 5 mg daily for the final week (total 11 weeks) 2
• This regimen reduces mortality and need for repeated pericardiocentesis 2

Polymyalgia Rheumatica

• Initial dose: 12.5-25 mg daily (lower doses preferred in patients with diabetes, osteoporosis, or glaucoma) 4
• Taper to 10 mg daily within 4-8 weeks, then by 1 mg every 4 weeks 4
• Never exceed 30 mg daily for this condition 4

Pediatric Dosing by Condition

Asthma Exacerbations (Age ≥12 years)

• 1-2 mg/kg/day (maximum 60 mg/day) for 3-10 days 2, 3, 1
• Use ideal body weight for significantly overweight children 3
• Single morning dose preferred to minimize adrenal suppression 3

Nephrotic Syndrome (First Episode)

• 60 mg/m² daily in 3 divided doses for 4 weeks, followed by 40 mg/m² as single dose on alternate days for 4 weeks 1
• Older boys (≥4 years) may benefit from higher initial doses (60 mg/m² vs 40 mg/m²) with lower relapse rates 5

Duchenne Muscular Dystrophy

• 0.75 mg/kg/day starting at age 6 years (±2 years) when plateau or decline in function occurs 2
• Maximum daily dose: 30 mg (based on 40 kg weight cap) 2
• Continue even when non-ambulatory to retard scoliosis and pulmonary decline 2

General Pediatric Range

• 0.14-2 mg/kg/day in 3-4 divided doses (equivalent to 4-60 mg/m² BSA/day) 1

Critical Safety Monitoring

Osteoporosis Prevention (Mandatory for All Patients)

• Any dose ≥2.5 mg/day for ≥3 months requires calcium 1,000-1,200 mg/day and vitamin D 600-800 IU/day supplementation 2, 4
• Perform FRAX fracture risk assessment with glucocorticoid dose adjustment for adults ≥40 years 2
• Adjust FRAX calculations: multiply hip fracture risk by 1.2 and major osteoporotic fracture risk by 1.15 if dose >7.5 mg/day 2
• Consider bisphosphonate therapy for high-risk patients at treatment initiation 2

Dose-Related Risk Thresholds

• Doses >30 mg/day are associated with significant mortality, particularly in elderly patients 4
• Very high-dose therapy (≥30 mg/day for ≥30 days or cumulative dose >5 grams/year) significantly increases fracture risk 4
• Severe complications (osteoporosis, diabetes, cataracts, hypertension, psychosis) typically develop only after 18 months of continuous therapy at doses >10 mg daily 4

Adrenal Suppression Management

• Taper gradually for any course >2-3 weeks to prevent adrenal crisis 2, 1
• Warn patients about steroid withdrawal syndrome (weakness, nausea, arthralgia, abdominal pain) which can mimic underlying disease 2
• Adrenal suppression occurs in approximately 50% of patients after medium- or high-dose therapy for prolonged periods 2

Additional Monitoring Requirements

• Monitor blood pressure, glycemic control, and serum potassium for prolonged courses 2
• Check serum aminotransferases monthly during tapering, as small dose decrements can cause marked biochemical changes 4
• Test stool for blood if anemic or suggestive history of gastrointestinal bleeding 2
• Annual ophthalmological examination for cataract screening 2
• Annual DEXA scan to monitor bone density 2

Administration Principles

Timing and Formulation

• Single morning dose preferred to minimize adrenocortical suppression 3, 1
• Divided doses (twice daily) acceptable for acute exacerbations 3
• Prednisolone is the active form; prednisone requires hepatic conversion but this is not a limiting factor even in severe liver disease 6

Dose Equivalencies

• 15 mg prednisolone = 15 mg prednisone = 60 mg hydrocortisone = 12 mg methylprednisolone = 2.25 mg dexamethasone 1
• These equivalencies apply only to oral/IV administration, not intramuscular or intra-articular routes 1

Common Pitfalls to Avoid

• Do not routinely taper short courses (≤10 days) as there is no evidence this prevents relapse 2, 3
• Do not use NSAIDs concurrently—prednisolone provides superior anti-inflammatory effects with fewer side effects and less expense 7
• Do not exceed 60 mg/day for asthma burst therapy in adolescents/adults 2, 3
• Do not forget calcium and vitamin D supplementation for any dose ≥2.5 mg/day for ≥3 months 2, 4
• Do not abruptly discontinue after long-term therapy—always taper gradually 1