Glucocorticoids
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Dosing and administration[2]
Oral prednisone (or equivalent), or IV methylprednisolone for severe disease. Lowest effective dose for the shortest duration; taper rather than stop abruptly after prolonged use. Add bone protection and consider Pneumocystis prophylaxis at higher or prolonged doses.
| Indication | Starting dose | Titration and maximum |
|---|---|---|
| Rheumatoid arthritis (bridging or flare) | Prednisone 5 to 10 mg daily (or less) for short-term bridging. | Taper to stop as the DMARD takes effect; avoid long-term low-dose steroid where possible. |
| Organ- or life-threatening disease (vasculitis, lupus nephritis) | Prednisone 0.5 to 1 mg/kg/day (up to about 60 to 80 mg/day), often after IV methylprednisolone pulses. | Taper over weeks to months guided by response, alongside a steroid-sparing agent. |
| Severe flare (pulse) | IV methylprednisolone 500 to 1000 mg daily for 1 to 3 days for severe or organ-threatening disease. | Follow with oral prednisone and taper. |
Onset. Onset within hours to days.
Principle: lowest effective dose for the shortest time, with a taper after prolonged use; steroids control inflammation but are bridging or adjunctive, not disease-modifying maintenance therapy.
Monitoring
- Blood pressure, blood glucose, weight, and (with prolonged use) bone mineral density.
- Bone protection (calcium, vitamin D, and a bisphosphonate or equivalent) for prolonged or higher-dose therapy.
- Consider Pneumocystis jirovecii prophylaxis at higher doses or with other immunosuppression.
- Do not withdraw abruptly after prolonged use (adrenal suppression).
Contraindications
- Systemic fungal infection.
- Live vaccines at immunosuppressive doses.
- Caution in diabetes, uncontrolled hypertension, osteoporosis, peptic ulcer disease, and serious infection.
Key interactions
- NSAIDs: increased gastrointestinal risk.
- CYP3A4 inhibitors and inducers alter steroid levels.
- Potassium loss with diuretics; hyperglycaemia with antidiabetic agents.
- Reduced vaccine response; avoid live vaccines at immunosuppressive doses.
Clinical notes
Common side effects
Short-term: appetite, mood and sleep disturbance, hyperglycaemia, fluid retention. Longer-term: osteoporosis, infection risk, ocular effects. Not sourced on this draft.
Tests and monitoring
With sustained use, monitor blood pressure and glucose, address bone protection, and consider vaccination status. Thresholds and bone-protection triggers to confirm from primary sources.
Important cautions
Infection risk, glycaemic effects, and interaction with comorbidity; avoid abrupt cessation after prolonged use. Carry steroid information for longer courses. To confirm from primary sources.
Primary sources to be used
- Primary sources for general (non-pregnancy) use to be attached: product monograph and the relevant ACR/EULAR treatment guideline.
- Prednisone and methylprednisolone Health Canada product monographs, with glucocorticoid dosing by clinical scenario per standard rheumatology practice. https://health-products.canada.ca/dpd-bdpp/