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Corticosteroids: Doses, Potency & Tapering

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1. Corticosteroid Equivalency Table

Source: Goodman & Gilman's Pharmacological Basis of Therapeutics, Table 30-1

• Dexamethasone is ~25x more potent than hydrocortisone and has NO mineralocorticoid effect - preferred when fluid retention must be avoided (e.g., cerebral edema, COVID-19 ARDS, dexamethasone 6 mg/day).
• Fludrocortisone is used exclusively for mineralocorticoid replacement (Addison's disease, adrenal insufficiency) - not for anti-inflammatory purposes.
• Dose equivalences apply to oral/IV routes. Potencies differ significantly for IM and intra-articular routes.

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2. Typical Dosing by Category

Low / Physiologic Dose

• Hydrocortisone 15-20 mg/day (replacement in adrenal insufficiency: 10 mg AM + 5 mg midday)
• Prednisone < 7.5 mg/day

Low-Moderate

• Prednisone 7.5-20 mg/day (e.g., mild RA, COPD exacerbation)

Moderate

• Prednisone 20-40 mg/day (e.g., asthma exacerbation, IBD flare)

High / Immunosuppressive

• Prednisone 40-60 mg/day (e.g., pemphigus, nephrotic syndrome, severe asthma)
• Methylprednisolone 1 mg/kg/day IV

Pulse / High-Dose IV

• Methylprednisolone 500-1000 mg/day IV x 3 days (e.g., MS relapse, lupus nephritis, vasculitis)
• Dexamethasone 6 mg/day x 10 days (COVID-19 ARDS - RECOVERY trial)
• Dexamethasone 4-16 mg/day (cerebral edema, anti-emesis)

Septic Shock

• Hydrocortisone 200 mg/day (by continuous infusion or 50 mg q6h) - per 2024 SCCM guidelines, when not responsive to fluids and vasopressors

Intra-articular Injections (reference)

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3. When to Taper (vs. Stop Abruptly)

• Prednisone ≥ 40 mg/day for > 1 week
• Any corticosteroid dose for > 3 weeks (regardless of dose)
• Doses taken repeatedly in the evening (evening doses suppress the HPA axis more)
• A course given within the past year in a patient with prior long-term therapy
• Patient has cushingoid appearance or received supraphysiological doses for 2-4 weeks in the preceding year

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4. Tapering Protocols

Standard Stepwise Taper (Prednisone Equivalents)

Source: Dermatology 2-Volume Set 5e; Goodman & Gilman's

Alternate-Day Tapering

• Once the daily dose reaches ~20-30 mg prednisone, convert to alternate-day therapy.
• Method 1 (simple): Multiply the daily dose by 2-2.5x for the "on-day" and rapidly reduce the "off-day" to zero.
• Method 2 (gradual): Increase the on-day dose by 5 mg and decrease the off-day dose by 5 mg at each step, until the off-day dose reaches zero.
• Alternate-day dosing reduces HPA suppression and side effects while maintaining therapeutic effect.

Long-Term / Chronic Therapy Taper

• Once at physiologic doses (≤ 5-7.5 mg prednisone, or 15-20 mg hydrocortisone equivalent), taper even more slowly - 1 mg every 4-6 weeks.
• At this stage, adrenal recovery may lag; check morning serum cortisol (6-8 AM) before each reduction. A level < 10 mcg/dL suggests ongoing HPA suppression.
• If needed, confirm with ACTH (cosyntropin) stimulation test (250 mcg IV/IM; check cortisol at 0, 30, 60 min - normal response: cortisol > 18-20 mcg/dL).

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5. Glucocorticoid Withdrawal Syndrome

• Fever
• Myalgia and arthralgias
• Fatigue and malaise
• This can mimic the underlying disease - distinguishing the two requires clinical judgment.

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6. Rules of Thumb

1. Take the morning dose - oral corticosteroids should be given as a single AM dose to mimic the natural cortisol peak and minimize HPA suppression.
2. Disease flare during taper - resume the last effective dose, then taper more slowly.
3. Perioperative stress dosing - patients on chronic steroids need stress-dose coverage for major surgery (hydrocortisone 50-100 mg IV q8h perioperatively), not just a brief taper.
4. Concurrent steroid-sparing agents - if a disease-modifying agent (methotrexate, azathioprine, etc.) is being added, begin steroid taper only after the sparing agent takes effect (typically 4-12 weeks depending on the agent).
5. Comorbidities to watch - diabetes (glucose monitoring), hypertension, osteoporosis (add calcium/vitamin D ± bisphosphonate if on > 3 months), peptic ulcers (add PPI if also on NSAIDs), and psychiatric history.

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• Goodman & Gilman's Pharmacological Basis of Therapeutics, Table 30-1 & Withdrawal of Therapy section
• Dermatology 2-Volume Set 5e (Tapering Systemic Glucocorticoids section)
• 2024 SCCM Guidelines on Corticosteroids in Sepsis/ARDS/CAP
• Endocrine Society 2024 Guideline on Glucocorticoid-induced Adrenal Insufficiency