Prednisone Dosing for Acute Tonsillitis
Prednisone 40-60 mg daily for 3-7 days should be considered only in adults with severe tonsillitis (Centor score 3-4) and must always be given in conjunction with appropriate antibiotic therapy. 1
When to Consider Corticosteroids
- Corticosteroids should NOT be routinely prescribed for acute tonsillitis, as most cases are self-limited and improve within 7-10 days with supportive care alone 1
- Consider a short course only in adults with severe presentations meeting 3-4 Centor criteria (fever >38°C, tonsillar exudates, tender anterior cervical lymphadenopathy, absence of cough) 1
- No evidence supports corticosteroid use in children with acute tonsillitis 1
- The benefit of steroids is considerably smaller in typical primary care populations where most patients do not have severe presentations 1
Specific Dosing Regimen
For adults with severe tonsillitis:
- Prednisone 40-60 mg daily for 3-7 days 1
- Administer as a single morning dose to minimize HPA axis suppression 2
- Oral administration is acceptable, though IV route may provide slightly greater effect 1
Alternative approach for very severe cases:
- Prednisone 0.5-1.0 mg/kg daily (maximum 80 mg daily) in tapering doses over 1-2 weeks, similar to dosing for other acute inflammatory conditions 3, 1
Critical Safety Requirements
Before initiating prednisone:
- Confirm bacterial tonsillitis with appropriate testing (rapid strep test or throat culture) 4, 5
- Always prescribe concurrent antibiotic therapy - penicillin is first-line for group A streptococcus 1, 4
- Screen for active infection, as current infection is a contraindication to corticosteroid monotherapy 2
Monitoring during treatment:
- Assess clinical response within 24-48 hours to ensure adequate disease control 2
- Monitor for dose-dependent side effects including hyperglycemia, hypertension, mood changes, and insomnia 2
Important Clinical Caveats
- The effect of steroids is smaller when given orally compared to IV administration 1
- Potential adverse effects include sleep disturbances, adrenal suppression, metabolic syndrome, weight gain, hypertension, and increased infection risk—even with short-term use 1
- Most acute tonsillitis is viral (70-95% of cases) and does not require antibiotics or corticosteroids 4
- For symptomatic relief in all patients, recommend ibuprofen or paracetamol regardless of corticosteroid use 1
Post-Tonsillectomy Context
If considering prednisone for post-operative pain management after tonsillectomy:
- Paracetamol/prednisolone combination is superior to paracetamol/ibuprofen for post-tonsillectomy recovery 6
- Prednisolone improves talking ability (p=0.03), reduces post-operative nausea and vomiting (p=0.049), and significantly decreases the incidence (p=0.046) and severity (p=0.045) of secondary hemorrhage compared to ibuprofen 6