Corticosteroid Equivalent Dosing and Clinical Applications

Core Conversion Ratios

The standard equivalent doses are: hydrocortisone 20 mg = prednisolone/prednisone 5 mg = methylprednisolone 4 mg = dexamethasone 0.75 mg, according to the Anaesthesia journal 1
Hydrocortisone is the baseline reference with a potency of 1x 1
Prednisolone/Prednisone is 4x more potent than hydrocortisone 2
Methylprednisolone is 5x more potent than hydrocortisone 2
Dexamethasone is 25x more potent than hydrocortisone 1, 2

For patients on chronic corticosteroids undergoing surgery, continue equivalent dosing intravenously until oral intake resumes, as recommended by the Gut journal 3
Prednisolone 5 mg oral is equivalent to Hydrocortisone 20 mg IV 3, 2
No evidence supports routine stress-dose supplementation beyond therapeutic replacement, according to the Anaesthesia journal 1
Dexamethasone 8 mg IV provides equivalent coverage to hydrocortisone 200 mg for 24 hours 1
The American College of Surgeons recommends using methylprednisolone 1-2 mg/kg/day (or prednisone dose equivalent) for grade 2-4 acute GVHD, as stated in the Journal of the National Comprehensive Cancer Network 5, 6
For grade 2+ pneumonitis, use prednisone 1 mg/kg/day or IV methylprednisolone equivalent, as recommended by the Journal for ImmunoTherapy of Cancer 7

All oral corticosteroids have excellent oral bioavailability and rapid absorption, according to the Anaesthesia journal 1
Hydrocortisone plasma elimination half-life is approximately 90 minutes 1
Dexamethasone provides longer duration of action despite similar absorption 1
IV infusion is superior to IM injection for maintaining physiologic cortisol concentrations during stress, as stated in the Anaesthesia journal 1

Hydrocortisone possesses mineralocorticoid activity, while synthetic corticosteroids have progressively less, according to the Praxis Medical Insights 4
Methylprednisolone causes significantly less hypokalemia than hydrocortisone at equivalent anti-inflammatory doses 4
Dexamethasone has no mineralocorticoid activity 1

Pneumocystis jirovecii prophylaxis is indicated for patients receiving ≥20 mg prednisone equivalent for ≥4 weeks, as recommended by the Journal for ImmunoTherapy of Cancer 7
Consider GI prophylaxis with proton pump inhibitors for patients on systemic corticosteroids 7
Calcium and vitamin D supplementation is recommended with prolonged steroid use 7