What is the recommended dosage of prednisolone (corticosteroid) for adults?

Prednisolone Dosing for Adults

For most adult inflammatory conditions, prednisolone should be initiated at 0.5-1 mg/kg/day (typically 40-60 mg daily as a single morning dose), tapered gradually over 6-8 weeks to the lowest effective maintenance dose, ideally ≤7.5 mg/day to minimize long-term toxicity. 1, 2

Initial Dosing Strategy by Disease Severity

The starting dose depends on disease severity and specific condition:

• Severe disease: 1-2 mg/kg/day (maximum 60 mg/day) 2
• Moderate disease: 0.5-1 mg/kg/day (typically 40 mg/day) 1, 2
• Mild disease: 0.3-0.5 mg/kg/day 2

Single daily dosing in the morning is as effective as divided dosing and causes less adrenal suppression. 1, 3 This approach is both more convenient and physiologically preferable.

Condition-Specific Dosing

Ulcerative Colitis

• 40 mg daily prednisolone, tapered over 6-8 weeks 1
• No benefit from doses exceeding 40-60 mg/day 1
• Patients not responding after 2 weeks require treatment escalation 1

Nephrotic Syndrome (Minimal Change Disease)

• 1 mg/kg/day (maximum 80 mg) as single daily dose OR 2 mg/kg (maximum 120 mg) on alternate days 1
• Maintain initial high dose for minimum 4 weeks if remission achieved, maximum 16 weeks if not 1
• Taper slowly over up to 6 months after achieving remission 1

Tuberculous Pericarditis

• 60 mg/day for 4 weeks, then 30 mg/day for 4 weeks, then 15 mg/day for 2 weeks, then 5 mg/day for 1 week 1
• This regimen significantly reduces mortality (3% vs 14%) 1

Autoimmune Hepatitis

• 60 mg daily as monotherapy OR 30 mg daily combined with azathioprine 50 mg daily 4
• Taper by 10 mg weekly initially, then by smaller increments 4

Inflammatory Myopathies

• 0.5-1 mg/kg/day (typically 60-80 mg/day) as single daily dose 1
• Taper by 10 mg every 2 weeks to 30 mg/day, then by 5 mg every 2 weeks to 20 mg/day, then by 2.5 mg every 2 weeks 1

Tapering Protocol

The standard taper reduces dose by one-third to one-quarter until reaching 15 mg/day, then by 2.5 mg increments to 10 mg/day, then by 1 mg monthly to reach minimum effective dose. 4 This gradual approach minimizes both adrenal insufficiency risk and disease flare.

For ulcerative colitis specifically: taper by 10 mg every 2 weeks to 30 mg/day, then by 5 mg every 2 weeks to 20 mg/day, then by 2.5 mg every 2 weeks until completion over 6-8 weeks total. 1

Maintenance Dosing

Target the lowest effective dose, ideally <7.5 mg/day, to minimize toxicity while maintaining disease control. 2 Research demonstrates that:

• 87% of patients can be maintained on ≤10 mg/day with satisfactory outcomes 4
• Doses <5 mg/day over long periods are effective for many chronic inflammatory conditions with acceptable side effect profiles 4, 5
• Low-dose prednisolone (<15 mg/day) is superior to NSAIDs for rheumatoid arthritis, reducing tender joints by 9 (5-12) and improving pain significantly 6, 7

Critical Safety Thresholds and Monitoring

Dose-Related Toxicity Thresholds

• Low-dose: <7.5 mg/day - Minimal toxicity risk 2
• Medium-dose: 7.5-30 mg/day - Moderate toxicity risk 2
• High-dose: >30 mg/day - Significant toxicity risk, particularly mortality in elderly 2, 4
• Very high-dose: ≥30 mg/day for ≥30 days or cumulative >5g/year - Dramatically increased fracture risk (vertebral RR 14, hip RR 3) 2, 4

Mandatory Prophylaxis

All patients receiving ≥2.5 mg/day for ≥3 months require:

• Calcium 1,000-1,200 mg/day 1, 2, 4
• Vitamin D 600-800 IU/day 1, 2, 4
• Bisphosphonate therapy for high-risk patients (prior fragility fracture, prolonged/repeated courses, age >40 with high FRAX score) 1

Adrenal Suppression

Any dose >7.5 mg/day for >3 weeks causes adrenal suppression risk. 2 Patients require:

• Gradual tapering when discontinuing (never abrupt cessation) 1, 8
• Warning about steroid withdrawal syndrome (weakness, nausea, arthralgia mimicking disease flare) 1
• Stress-dose coverage consideration during illness or surgery 2

Monitoring Requirements

• Blood pressure, glucose, and potassium - Monitor regularly on prolonged therapy 1
• Bone mineral density - Baseline and annually for long-term therapy 4
• Disease-specific markers - Monthly during tapering (e.g., aminotransferases for hepatitis, as small decrements can cause marked biochemical changes) 4

Common Pitfalls to Avoid

1. Do not use uniform dosing without weight adjustment - Weight-based dosing (mg/kg) optimizes efficacy while minimizing toxicity 2

2. Do not exceed 40-60 mg/day for most conditions - Higher doses provide no additional benefit but increase adverse effects significantly 1

3. Do not taper too rapidly - Abrupt withdrawal or overly aggressive tapering causes both adrenal crisis and disease flare 1, 8

4. Do not neglect osteoporosis prevention - Begin calcium, vitamin D, and bisphosphonates (when indicated) at treatment initiation, not after fractures occur 1, 2, 4

5. Do not prolong high-dose therapy unnecessarily - Severe complications (osteoporosis, diabetes, cataracts, psychosis) typically develop only after 18 months of continuous therapy at doses >10 mg/day 4

6. Do not use divided dosing routinely - Single morning dosing is equally effective with less adrenal suppression 1, 3

Dose Equivalency

Prednisolone 5 mg = Prednisone 5 mg = Methylprednisolone 4 mg = Hydrocortisone 20 mg 2, 9, 8

This conversion is critical for perioperative management when switching between oral and IV formulations. 9