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Systemic Corticosteroid (IV Pulse / Depot) Pregnancy: Use only if benefit outweighs risk — prednisolone preferred in pregnancy as less crosses placenta. IV pulse: specialist decision only.

Methylprednisolone

Brand names: Solu-Medrone (IV/IM), Depo-Medrone (depot IM/intra-articular), Medrone (oral)

Adult dose

Dose: IV pulse (severe inflammation/autoimmune): 500mg–1g IV OD for 1–3 days. Spinal cord injury (within 8h of injury, NASCIS protocol — controversial): 30mg/kg IV over 15 min, then 5.4mg/kg/h for 23h. MS relapse: 1g IV OD for 3–5 days. Organ transplant rejection: 0.5–1g IV OD for 1–3 days. Intra-articular (Depo-Medrone): 40–80mg per large joint (hip, knee) up to every 3 months.
Route: IV infusion (pulse) / IM (depot) / Intra-articular
Frequency: Once daily (pulse); see intra-articular dosing per indication
Max: 1g IV per pulse; 3 days maximum for most IV pulse indications
Methylprednisolone 4mg ≡ prednisolone 5mg. IV pulse therapy causes rapid lymphocyte suppression. Cardiac arrhythmias (bradycardia, VT) reported with rapid IV infusion — always infuse over 30 minutes. Depo-Medrone depot lasts 3–6 weeks. NASCIS protocol use in spinal cord injury is controversial and not universally recommended.

Paediatric dose

Dose: 10 mg/kg
Route: IV
Frequency: Once daily for 3 days
Max: 1g per dose
BNFc: IV pulse: 10–30mg/kg OD (max 1g) for 1–3 days. MS relapse: 20–30mg/kg/day (max 1g) for 3–5 days. Seek specialist paediatric neurology/rheumatology opinion.

Dose adjustments

Renal

No specific dose adjustment — monitor fluid balance carefully in renal impairment (fluid retention risk).

Hepatic

Use with caution in severe hepatic impairment — monitor for enhanced effects.

Paediatric weight-based calculator

BNFc: IV pulse: 10–30mg/kg OD (max 1g) for 1–3 days. MS relapse: 20–30mg/kg/day (max 1g) for 3–5 days. Seek specialist paediatric neurology/rheumatology opinion.

Clinical pearls

  • Infuse IV pulses over at least 30 minutes — rapid infusion associated with cardiac arrhythmias and sudden death in case reports
  • Post-pulse hyperglycaemia: blood glucose may rise markedly for 24–48h after IV methylprednisolone — check glucose 2–4 hourly in inpatients; may require insulin
  • Avascular necrosis: cumulative dose >2g associated with AVN of femoral head — warn patient of hip pain as red flag
  • Intra-articular Depo-Medrone: limit to 3–4 per joint per year — cartilage damage with excessive injections; each injection raises blood glucose for 48–72h in diabetics

Contraindications

  • Systemic infection without antimicrobial cover
  • Live vaccines
  • Hypersensitivity to methylprednisolone
  • Rapid IV injection (cardiac risk)

Side effects

  • Bradycardia/cardiac arrhythmias (rapid IV infusion)
  • Severe hyperglycaemia (post-pulse)
  • Insomnia, mood disturbance
  • GI haemorrhage
  • Immunosuppression
  • Osteoporosis (long-term)
  • Cushing's syndrome (repeated pulses)
  • Avascular necrosis of femoral head (high cumulative dose)

Interactions

  • Antifungals (fluconazole, itraconazole) — CYP3A4 inhibition increases methylprednisolone exposure
  • Rifampicin — CYP3A4 induction significantly reduces efficacy
  • Antidiabetics — dose adjustment required post-pulse (severe hyperglycaemia)
  • Cyclosporin — mutually inhibit metabolism; increased levels of both

Monitoring

  • Blood glucose (every 4–6h post-pulse)
  • Blood pressure
  • Cardiac monitoring during infusion
  • FBC, electrolytes
  • Bone density (DEXA) if repeated pulses

Reference: BNFc; BNF 90; NICE CG186 (Multiple Sclerosis); BSR Guidelines on Rheumatoid Arthritis. Verify against your local formulary and the latest BNF before prescribing.

Related

Curated clinical cross-links plus same-class fallbacks.

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