What are the recommended prednisolone doses for adults with acute asthma exacerbation, COPD flare, rheumatoid arthritis, severe dermatologic inflammation, for children, and how should dosing be adjusted in elderly patients with comorbidities?

Prednisolone Dosing Recommendations

Acute Asthma Exacerbation

Adult Dosing

For adults with acute asthma exacerbation, prescribe oral prednisolone 40-60 mg once daily for 5-10 days without tapering, continuing until peak expiratory flow reaches ≥70% of predicted or personal best. 1

• Oral administration is strongly preferred and equally effective as intravenous therapy when gastrointestinal absorption is intact 1, 2
• For severe exacerbations requiring hospitalization, use 40-80 mg daily in divided doses until PEF reaches 70% of predicted 1
• If the patient is vomiting or severely ill, administer IV hydrocortisone 200 mg immediately, then 200 mg every 6 hours 2
• Alternative IV option: methylprednisolone 125 mg initially, then transition to oral therapy once tolerated 3

Pediatric Dosing

For children with acute asthma exacerbation, prescribe prednisolone 1-2 mg/kg/day in 2 divided doses (maximum 60 mg/day) for 3-10 days without tapering. 1

• Calculate dose based on ideal body weight in overweight children to avoid excessive steroid exposure 1
• For a typical 8-year-old (ideal weight 25-30 kg), the appropriate dose is 25-60 mg/day, capped at 60 mg maximum 1
• Continue until PEF reaches ≥70% of predicted or personal best 1

Duration and Tapering

• Total course typically lasts 5-10 days for outpatient management 1
• No tapering is necessary for courses less than 7-10 days, especially if patients are concurrently taking inhaled corticosteroids 1
• Tapering short courses is unnecessary and may lead to underdosing during the critical recovery period 1

Critical Timing

• Administer systemic corticosteroids within 1 hour of emergency department presentation, as anti-inflammatory effects take 6-12 hours to become apparent 1
• Early administration is crucial—delaying corticosteroids while repeatedly giving bronchodilators is a dangerous pitfall 1

COPD Exacerbation

The provided evidence does not contain specific prednisolone dosing recommendations for COPD exacerbations. Based on general medical knowledge, typical dosing is prednisolone 30-40 mg daily for 5-7 days, but this should be confirmed with COPD-specific guidelines.

Rheumatoid Arthritis

Maintenance Therapy

For rheumatoid arthritis, use low-dose prednisolone ≤10 mg/day (often 5 mg twice daily) as part of long-term disease management, initiated early with another DMARD. 4, 5

• Doses should not exceed 10 mg/day and are often given in divided doses (5 mg BID) for optimal inflammatory control 4
• Prednisolone <5 mg/day over long periods appears acceptable and effective for many patients 6
• Low-dose prednisolone (10 mg daily or 5 mg BID) controls most inflammatory features of early polyarticular RA and retards bony damage 5

Tapering Strategy

• Taper slowly using 1 mg decrements every 2 weeks to 1 month 4
• Do not consider it a failure to maintain patients on the lowest effective dose indefinitely 4

Bone Protection

• Always initiate supplemental calcium 800-1,000 mg/day and vitamin D 400-800 units/day with treatment 4
• Monitor bone status with DEXA scans at 1-2 yearly intervals while on steroids 7

Severe Dermatologic Inflammation (Bullous Pemphigoid)

Initial Dosing by Severity

For severe widespread bullous pemphigoid, prescribe prednisolone 0.75-1 mg/kg/day; for moderate disease use 0.3 mg/kg/day; for mild or localized disease use 0.5 mg/kg/day. 7

• For a 70 kg patient with severe disease, this translates to approximately 52.5-70 mg/day 7
• Treatment is effective within 1-4 weeks in about 60-90% of cases 7

Dose Reduction

• If new inflammatory or blistered lesions are few or absent within 4 weeks, begin gradual dose reduction 7
• Reduce by one-third or one-quarter at fortnightly intervals down to 15 mg daily 7
• Then reduce by 2.5 mg decrements down to 10 mg daily 7
• Finally reduce by 1 mg each month 7
• Approximately 50% of patients will relapse during dose reduction, indicating the previous dose is the minimal effective dose 7

Autoimmune Hepatitis

Initial Treatment

For autoimmune hepatitis, initiate prednisolone 30 mg/day, reducing to 10 mg/day over 4 weeks, combined with azathioprine 1 mg/kg/day. 7

• Higher initial doses up to 1 mg/kg/day may result in more rapid normalization of transaminases 7
• Exercise caution in frail elderly patients 7
• Continue prednisolone 5-10 mg/day plus azathioprine for at least 2 years and for at least 12 months after normalization of transaminases 7

Vasculitis (Polyarteritis Nodosa)

Severe Disease

For newly diagnosed active, severe PAN, initiate IV pulse methylprednisolone 500-1,000 mg/day (adults) or 30 mg/kg/day (children; maximum 1,000 mg/day) for 3-5 days, followed by high-dose oral prednisone 1 mg/kg/day (generally up to 80 mg/day for adults). 7

Nonsevere Disease

• Moderate-dose oral prednisone 0.25-0.5 mg/kg/day (generally 10-40 mg/day for adults) is appropriate for nonsevere disease 7

Maintenance

• Low-dose oral prednisone ≤10 mg/day (adults) is used for maintenance therapy 7

Elderly Patients and Comorbidities

Dose Adjustments

• Exercise caution with initial dosing in frail elderly patients—consider starting at the lower end of recommended ranges 7
• For glucocorticoid-induced osteoporosis prevention, adults ≥40 years at very high fracture risk (≥30 mg daily for ≥30 days or cumulative dose ≥5 g over 1 year) should receive bone-protective therapy 7
• Ensure calcium and vitamin D supplementation in all elderly patients on corticosteroids 7, 4
• Perform DEXA scanning at 1-2 yearly intervals while on steroids and actively treat osteopenia/osteoporosis 7

Common Pitfalls to Avoid

• Do not use unnecessarily high doses—higher doses of corticosteroids have not shown additional benefit in severe exacerbations but increase adverse effects 1, 8
• Do not delay systemic corticosteroid administration in acute conditions—underuse is a documented factor in preventable deaths 1
• Do not taper short courses (<7-10 days) unnecessarily 1
• Do not dose pediatric patients based on actual body weight in significantly overweight children—use ideal body weight 1