What are the recommended dosing, tapering schedule, contraindications, and monitoring parameters for prednisolone in adults and children?

Prednisolone Dosing, Tapering, Contraindications, and Monitoring

Adult Dosing by Indication

Autoimmune Hepatitis

Prednisolone 1 mg/kg daily (or prednisone 40-60 mg daily) in combination with azathioprine 1-2 mg/kg daily is the preferred first-line regimen. 1

• Start prednisolone at 1 mg/kg daily (Europe) or prednisone 40-60 mg daily (United States) with azathioprine 50-150 mg daily 1
• Taper prednisolone over 6-8 months to 5-10 mg daily once biochemical response is achieved by 4-8 weeks 1
• Maintain azathioprine throughout the taper and continue as monotherapy after steroid withdrawal 1
• Prednisone monotherapy (40-60 mg daily) is appropriate only when treatment duration is expected to be <6 months or azathioprine is contraindicated 1
• Prolonged prednisone monotherapy, especially at doses >10 mg daily, should be avoided due to well-known drug toxicities 1

Acute Severe Ulcerative Colitis

Methylprednisolone 60 mg daily or hydrocortisone 100 mg every 6 hours intravenously is the cornerstone of treatment. 1

• Methylprednisolone 60 mg daily has less mineralocorticoid effect than hydrocortisone and causes significantly less hypokalemia 1
• Hydrocortisone 400 mg daily is equivalent to 80 mg methylprednisolone 1
• Assess for clinical and biochemical response after 3 days to determine need for salvage therapy 1
• Extending therapy beyond 7-10 days carries no additional benefit and increases toxicity 1

Asthma Exacerbations (Adults)

Prednisone 40-60 mg daily as a single morning dose or in 2 divided doses for 5-10 days without tapering is the standard outpatient regimen. 2, 3

• For severe exacerbations requiring hospitalization, use 40-80 mg daily until peak expiratory flow reaches 70% of predicted or personal best 2
• Oral administration is strongly preferred and equally effective as intravenous therapy when gastrointestinal absorption is intact 2
• No tapering is necessary for courses lasting 5-10 days, especially if the patient is concurrently taking inhaled corticosteroids 2
• Higher doses (>60 mg/day) have not shown additional benefit in severe exacerbations but increase adverse effect risk 2

Rheumatoid Arthritis

Low-dose prednisone ≤10 mg daily, often given as 5 mg twice daily, is safe and effective for long-term management. 4

• Prednisone should be initiated as early as possible, usually with another DMARD 4
• Supplemental calcium 800-1,000 mg/day and vitamin D 400-800 units/day should always be initiated with treatment 4
• Taper slowly using 1 mg decrements every 2-4 weeks to the lowest effective dose 4
• Doses ≤15 mg daily have a marked effect over placebo on joint tenderness, pain, and grip strength 5

Systemic Lupus Erythematosus

For serologically active but clinically stable SLE, prednisone 30 mg/day for 2 weeks, 20 mg/day for 1 week, then 10 mg/day for 1 week can avert severe flares. 6

• This short-term regimen is indicated when both anti-dsDNA levels increase by 25% and C3a levels increase by 50% over previous monthly visits 6
• This approach prevents severe flares requiring >40 mg/day prednisone or addition of immunosuppressive agents 6

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Pediatric Dosing by Indication

Autoimmune Hepatitis

Prednisone 1-2 mg/kg daily (maximum 40-60 mg/day) with azathioprine 1-2 mg/kg daily is the initial regimen. 1

• Taper prednisone over 6-8 weeks to 0.1-0.2 mg/kg daily or 5 mg daily with azathioprine 1
• Continue until normal liver tests for 1-2 years during treatment with no flare during entire interval 1
• Early use of azathioprine is recommended for all children without contraindications to minimize long-term corticosteroid effects on growth, bone development, and physical appearance 1

Asthma Exacerbations (Children)

Prednisone or prednisolone 1-2 mg/kg/day in 2 divided doses (maximum 60 mg/day) for 3-10 days without tapering is the standard regimen. 2, 3

• For overweight children, calculate the dose based on ideal body weight rather than actual weight to avoid excessive steroid exposure 2
• The maximum daily dose is 60 mg regardless of weight 2, 3
• No tapering is required for short courses of 5-10 days 2, 3
• Oral administration is preferred; reserve IV hydrocortisone 4 mg/kg for patients who are vomiting or severely ill 2

Nephrotic Syndrome

Prednisolone 60 mg/m²/day or 2 mg/kg/day (maximum 60 mg/day) for 4-6 weeks is the standard initial regimen. 7, 3

• This regimen is for children under 12 years with new nephrotic syndrome without syndromic features 7
• Glucocorticoids should be initiated without requiring a kidney biopsy first 7
• The primary target population is children older than 1 year, as infants under 1 year are more likely to have a genetic etiology 7

Juvenile Idiopathic Arthritis-Associated Uveitis

Prednisolone acetate 1% topical drops are conditionally recommended over difluprednate for active chronic anterior uveitis. 1

• Adding or increasing topical glucocorticoids for short-term control is preferred over adding systemic glucocorticoids 1
• If still requiring 1-2 drops/day of prednisolone acetate 1% for at least 3 months despite systemic therapy, changing or escalating systemic therapy is recommended 1

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Tapering Schedules

Short-Course Therapy (<7-10 Days)

No tapering is necessary for courses lasting less than 7-10 days, especially if patients are concurrently taking inhaled corticosteroids. 2, 3

• Tapering short courses is unnecessary and may lead to underdosing during the critical recovery period 2
• This applies to both adults and children 2, 3

Autoimmune Hepatitis Taper

Taper prednisone from 20 mg daily onward by 5 mg every week until 10 mg/day, then by 2.5 mg/week to 5 mg daily. 1

• Continue maintenance regimen until resolution of disease, treatment failure, or drug intolerance 1
• Prednisone may be discontinued completely once biochemical remission is achieved, leaving the patient on azathioprine alone 1

Rheumatoid Arthritis Taper

Taper slowly using 1 mg decrements every 2-4 weeks to the lowest effective dose. 4

• Do not deem it a failure to hold the patient on the lowest effective dose of prednisone 4
• The goal is to maintain doses ≤10 mg daily 4

Long-Term Therapy Discontinuation

If stopping after long-term therapy, withdraw gradually rather than abruptly. 3

• For slightly longer courses (up to 10 days), there probably is no need to taper, especially if patients are concurrently taking inhaled corticosteroids 1

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Contraindications and Precautions

Absolute Contraindications

• Complete TPMT deficiency (for combination therapy with azathioprine) 1
• Known azathioprine intolerance (for combination therapy) 1

Relative Contraindications for Autoimmune Hepatitis Treatment

The following conditions require careful risk-benefit assessment but are not absolute contraindications: 1

• Brittle diabetes 1
• Obesity 1
• Acne 1
• Malignancy 1
• Emotional lability 1
• Hypertension 1
• Osteopenia with vertebral compression 1

Pregnancy Considerations

Prednisolone can be used during pregnancy in equivalent doses to prednisone. 1

• In Europe, prednisolone is preferred over prednisone 1
• Azathioprine-related adverse events have not been reported in pregnancy or baby, though risk of preterm birth is increased 1
• Women with cirrhosis who are pregnant or plan to become pregnant should be screened for varices by endoscopy 1

Vaccination Considerations

For patients taking the equivalent of prednisone ≤10 mg daily, administering any non-live vaccinations is strongly recommended. 1

• For prednisone >10 mg but <20 mg daily, administering any non-live attenuated vaccinations is conditionally recommended 1
• For prednisone ≥20 mg daily, administering influenza vaccination is conditionally recommended 1
• For prednisone ≥20 mg daily, deferring non-live attenuated vaccinations (other than influenza) until glucocorticoids are tapered to <20 mg daily is conditionally recommended 1
• Live attenuated vaccines should be deferred in patients taking immunosuppressive medication 1

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Monitoring Parameters

Baseline Monitoring

Before initiating prednisolone therapy, obtain: 1

• Complete blood count (FBC) 1
• C-reactive protein (CRP) 1
• Urea and electrolytes (U&E) 1
• Liver function tests (LFTs) 1
• Magnesium 1
• Baseline bone mineral densitometry of lumbar spine and hip for patients anticipated to require long-term therapy 1

Ongoing Monitoring for Long-Term Therapy

Patients on long-term corticosteroid treatment require: 1, 7

• Annual bone mineral densitometry of lumbar spine and hip 1
• Laboratory testing every 3-4 months once biochemical remission is achieved 1
• Growth velocity monitoring in children (most sensitive indicator of systemic corticosteroid exposure) 7
• Blood pressure monitoring at each visit using age and height-specific percentiles in children 7
• Annual screening for cataracts in children on therapy for more than 3 months 7
• Annual DEXA scans and vitamin D monitoring for long-term use in children 7
• Urine glucose screening and blood glucose if positive in children 7

Acute Severe Ulcerative Colitis Monitoring

During inpatient treatment, monitor: 1

• Accurate stool chart recording frequency, consistency, and presence of blood 1
• Repeat blood gases within 2 hours if initial PaO2 <8 kPa (60 mmHg) or if patient deteriorates 1
• Peak expiratory flow 15-30 minutes after starting treatment for asthma exacerbations 2

Asthma Exacerbation Monitoring

Continue treatment until peak expiratory flow reaches ≥70% of predicted or personal best. 2, 3

• Measure peak expiratory flow 15-30 minutes after starting treatment 2
• Reassess patients after initial bronchodilator dose and after 60-90 minutes of therapy 2

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Common Pitfalls and How to Avoid Them

Underdosing in Acute Exacerbations

Do not underdose systemic corticosteroids in acute asthma exacerbations, as this is a documented cause of preventable asthma deaths. 2

• Administer systemic corticosteroids early in all moderate-to-severe exacerbations 2
• Do not delay corticosteroid administration while repeatedly giving bronchodilators alone 2
• Anti-inflammatory effects take 6-12 hours to become apparent, making early administration crucial 2

Unnecessary Tapering

Do not taper short courses (less than 7-10 days) of corticosteroids, as this is unnecessary and may lead to underdosing during the critical recovery period. 2, 3

• This applies to both adults and children 2, 3
• Tapering is especially unnecessary if patients are concurrently taking inhaled corticosteroids 2

Excessive Dosing in Children

For overweight children, calculate the dose based on ideal body weight rather than actual weight to avoid excessive steroid exposure. 2

• Using actual body weight in significantly overweight children leads to excessive steroid exposure without additional benefit 2
• The maximum daily dose is 60 mg regardless of weight 2, 3

Prolonged High-Dose Monotherapy

Avoid prolonged prednisone monotherapy, especially at doses >10 mg daily, due to well-known drug toxicities. 1

• The combination regimen of prednisone and azathioprine is associated with lower occurrence of corticosteroid-related side effects than higher-dose prednisone regimen (10% versus 44%) 1
• Cosmetic changes occur in 80% of patients after 2 years of corticosteroid treatment regardless of regimen 1
• Severe complications (osteoporosis with vertebral compression, brittle diabetes, psychosis) usually occur after protracted therapy (>18 months) with prednisone alone at 20 mg daily 1

Inadequate Bone Protection

Always initiate supplemental calcium 800-1,000 mg/day and vitamin D 400-800 units/day with corticosteroid treatment. 4

• Patients on long-term therapy require annual bone mineral densitometry 1
• This is critical to prevent osteopenia and vertebral compression 1

Inappropriate Route Selection

Do not use intravenous corticosteroids when oral administration is possible, as oral therapy is equally effective and less invasive. 2

• Reserve IV administration for patients who are vomiting, severely ill, or have impaired gastrointestinal absorption 2
• There is no advantage to IV administration over oral therapy when GI function is intact 2