Corticosteroid Therapy

Introduction to Corticosteroids

• Corticosteroids have various potencies, durations of action, and mineralocorticoid activities, and selection should consider these factors, as recommended by the American College of Physicians 1
• Equivalent doses of corticosteroids can be used as a reference for clinical decision-making:

2

• The potency ratios relative to prednisone are as follows:

3, 4

Dosage and Conversion

• The conversion ratio between methylprednisolone and prednisone is 1:1.25, with methylprednisolone being 1.25× more potent than prednisone, as supported by the European Society of Cardiology and the American Society of Clinical Oncology 3, 4
• To convert from methylprednisolone to prednisone, multiply the methylprednisolone dose by 1.25 to get the equivalent prednisone dose, or divide the prednisone dose by 1.25 to get the equivalent methylprednisolone dose, as recommended by the European Society of Cardiology and the American Society of Clinical Oncology 3, 4

Specific Indications and Dosages

• For polymyalgia rheumatica, the recommended dose range is 12.5-25 mg prednisone equivalent daily, which converts to 10-20 mg of methylprednisolone, as recommended by the European League Against Rheumatism 4
• For idiopathic focal segmental glomerulosclerosis (FSGS) with nephrotic syndrome, the Kidney Disease: Improving Global Outcomes (KDIGO) guidelines recommend prednisone at a daily single dose of 1 mg/kg (maximum 80 mg) or alternate-day dose of 2 mg/kg (maximum 120 mg), based on moderate to high-quality evidence 5
• For septic shock, hydrocortisone is commonly used at a dose of 200-300 mg/day, as recommended by the British Medical Journal 1
• For COVID-19-related ARDS, dexamethasone is recommended, with a mortality benefit observed in patients requiring oxygen or mechanical ventilation, based on moderate to high-quality evidence 6
• For chemotherapy-induced nausea/vomiting prevention, dexamethasone is recommended, with a dose of 10 mg IV on day 1, then days 2-4 for high emetic risk, according to the Journal of Clinical Oncology, with a strength of evidence rated as high 7
• For patients with severe tonsillitis, significant inflammation, and difficulty swallowing, the American Heart Association recommends considering initial IV methylprednisolone 1-2 mg/kg/day 8

Monitoring and Adverse Effects

• The American College of Physicians recommends monitoring for hyperglycemia, hypertension, and electrolyte abnormalities with all corticosteroids, as well as being aware of the risk of adrenal suppression with longer courses (>14 days) of therapy, based on high-quality evidence 1
• Patients on low-dose glucocorticoid therapy (≤7.5 mg prednisone equivalent daily) require standard care monitoring, except for osteoporosis, baseline assessments of ankle edema, fasting blood glucose, and risk factors for glaucoma, as recommended by the European League Against Rheumatism, with a moderate level of evidence supporting this recommendation 9
• For medium to high-dose therapy, more extensive monitoring is required to assess potential adverse effects on bone health, cardiovascular system, and metabolic parameters, according to the European League Against Rheumatism, with a high level of evidence supporting this recommendation 10

Discontinuation and Tapering

• Avoid abrupt discontinuation of either medication to prevent adrenal insufficiency, and consider tapering schedules when discontinuing either medication, as suggested by the American College of Rheumatology 4
• Inflammation may recur after discontinuing corticosteroid therapy, especially when stopped abruptly, according to the British Medical Journal, with a moderate level of evidence supporting this statement 1