For clinicians
Glucocorticoids
prednisone, prednisolone, steroids, corticosteroids
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Bottom lineBottom line: non-fluorinated glucocorticoids (prednisone/prednisolone) are usable throughout pregnancy at the lowest effective dose; useful for flare control. Higher/prolonged exposure raises risks of gestational diabetes, hypertension, PPROM, and growth restriction. Compatible with lactation. EULAR 2024 emphasises dose minimisation more firmly than earlier guidance.
By reproductive phase
| Phase | Position | Detail | Evidence |
|---|---|---|---|
| Pre-conception | Use if needed | Use lowest effective dose; taper where possible before conception.[1, 2] | ●●●○moderate evidenceconditional |
| 1st trimester | Use if needed | Usable at lowest effective dose. A historical cleft-palate signal is weak and unconfirmed.[1, 2, 3] | ●●●○moderate evidenceconditional |
| 2nd/3rd trimester | Use if needed | Usable at lowest effective dose; monitor for GDM, hypertension, PPROM, and IUGR with higher/prolonged exposure.[1, 2] | ●●●○moderate evidenceconditional |
| Breastfeeding | Continue | Compatible with lactation; with high doses some suggest delaying feeding ~4 hours, though transfer is low.[2, 3] | ●●●○moderate evidenceconditional |
| Paternal | Continue | Compatible with paternal exposure.[2] | ●●○○low evidenceconditional |
Guideline comparison
| Guideline | Position | Strength |
|---|---|---|
| ACR 2020 | Conditionally recommend continuing low-dose non-fluorinated glucocorticoids (prednisone <=10 mg/day or equivalent) when clinically indicated. Strongly recommend tapering higher doses to <20 mg/day by adding a pregnancy-compatible steroid-sparing agent. Breastfeeding: compatible; after a dose >20 mg, delay breastfeeding for 4 hours. Delivery: conditionally against routine stress-dose steroids for vaginal delivery, conditionally recommend them for cesarean. ACR gives no paternal recommendation for glucocorticoids.[1] | Conditional (continue low-dose <=10 mg/day); strong (taper higher doses to <20 mg/day) |
| EULAR 2024 | Prednisone/prednisolone can be used in pregnancy (2a/B); taper to a maintenance dose <=5 mg/day and withdraw where possible, weighing higher doses against maternal-foetal complications. Compatible with lactation (2a/B). Continuable in men (2b/B).[2] | Oxford LoE/GoR as shown |
| BSR 2022/23 | Prednisolone compatible across peri-conception, both trimesters, breastfeeding, and paternal exposure.[3] | Verified against BSR Table 1 |
=Guideline divergence. VERIFIED DIVERGENCE (emphasis). BSR 2023 marks prednisolone compatible across all five phases. EULAR 2024 permits prednisone/prednisolone in pregnancy (2a/B) but adds an explicit dose ceiling: taper where possible to a maintenance dose of <=5 mg/day and withdraw when possible, weighing higher doses against maternal-foetal complications. EULAR's stance is more restrictive on dose than BSR's binary compatibility grid conveys.
Key points
| Point | Evidence |
|---|---|
| Lowest effective dose principle; steroid-sparing agents preferred for maintenance.[2] | ●●●○moderate evidenceconditional |
Special populations
- Fluorinated steroids bypass placental 11-beta-HSD2 and are reserved for fetal indications (e.g. fetal lung maturation, some anti-Ro contexts), not routine maternal disease. ●●●○moderate evidenceconditional[1]
Monitoring
- Monitor blood pressure and glucose, especially with higher or prolonged doses.
- Consider steroid-sparing agents to reduce maintenance dose.
References
- Sammaritano LR, et al. 2020 ACR Guideline for the Management of Reproductive Health in RMD. Arthritis Rheumatol. 2020;72(3):529-556. https://acrjournals.onlinelibrary.wiley.com/doi/10.1002/art.41191
- Ruegg L, et al. EULAR recommendations for antirheumatic drugs in reproduction, pregnancy, and lactation: 2024 update. Ann Rheum Dis. 2025;84(6):910-926. https://ard.eular.org/article/S0003-4967(25)00818-0/fulltext
- Russell MD, et al. BSR guideline on prescribing drugs in pregnancy and breastfeeding: immunomodulatory drugs and corticosteroids. Rheumatology (Oxford). 2023;62(4):e48-e88. https://academic.oup.com/rheumatology/article/62/4/e48/6783012