Systemic Corticosteroid Pregnancy: Use only if benefit outweighs risk — crosses placenta (90% inactivated). Associated with fetal cleft palate (first trimester). Preferred steroid in pregnancy as largely metabolised before reaching fetus (unlike dexamethasone/betamethasone).

Prednisolone (Systemic)

Brand names: Deltacortril, Deltastab

Adult dose

Dose: Inflammatory/autoimmune: 20–60mg OD initially; taper based on clinical response. Adrenal insufficiency (replacement): 5–7.5mg OD (divided). Asthma exacerbation: 40–50mg OD for 5 days. Temporal arteritis/PMR: 40–60mg OD initially. Palliative: 8mg OD (symptom control). Anti-emetic (chemotherapy): 8–16mg OD.

Route: Oral

Frequency: Once daily in morning (to mimic cortisol diurnal rhythm and minimise HPA suppression) or divided BD

Max: 60mg OD for most indications; higher doses used in specialist settings (e.g. pemphigus, organ transplant)

Prednisolone 5mg ≡ hydrocortisone 20mg ≡ dexamethasone 0.75mg (approximate equivalence). Always carry steroid card. Taper slowly if >3 weeks therapy — risk of adrenal insufficiency on abrupt withdrawal. Sick day rules: double dose during intercurrent illness.

Paediatric dose

Dose: 1 mg/kg

Route: Oral

Frequency: Once daily in morning

Max: 40mg OD

BNFc: General anti-inflammatory/immunosuppressive: 1–2mg/kg OD (max 40mg). Croup: 1mg/kg single dose (max 20mg) — dexamethasone often preferred. Asthma exacerbation: 1mg/kg OD for 3–5 days (max 40mg). Seek paediatric specialist opinion for long-term use.

Dose adjustments

Renal

No dose adjustment required. Monitor fluid retention and electrolytes — corticosteroids may cause fluid overload in renal impairment.

Hepatic

Prednisolone active drug (not prodrug like prednisone) — use with caution in severe hepatic impairment; monitor for enhanced effects.

Paediatric weight-based calculator

Patient weight (kg)

Clinical pearls

Prescribe bone protection: calcium + vitamin D (Calcichew D3) for any course >3 months; add bisphosphonate if T-score <-1.5 or high fracture risk (NICE CG146)
Sick day rules: patients on long-term steroids must DOUBLE their dose during illness — failure to do so risks adrenal crisis
Antidote for adrenal crisis: hydrocortisone 100mg IV/IM stat (not prednisolone — needs IV delivery for emergency)
Steroid card + medic alert bracelet: mandatory for all long-term users — carries information for emergency treatment

Contraindications

Systemic infection (without antibiotic cover)
Live vaccines (immunosuppressive doses)
Hypersensitivity to prednisolone

Side effects

Hyperglycaemia (steroid-induced diabetes)
Hypertension
Osteoporosis (long-term)
Adrenal suppression
Cushing's syndrome features (moon face, striae, weight gain)
Peptic ulcer (particularly with NSAIDs)
Proximal myopathy
Mood disturbance/psychosis
Impaired wound healing
Increased infection susceptibility
Cataracts (posterior subcapsular — long-term)
Growth suppression (children)

Interactions

NSAIDs — additive peptic ulcer risk
Warfarin — variable effect; monitor INR
Antidiabetics — antagonise glucose control; adjust doses
Rifampicin — CYP3A4 induction; significantly reduces prednisolone levels (double dose may be needed)
Live vaccines — contraindicated in immunosuppressive doses
Carbamazepine, phenytoin — reduce corticosteroid efficacy

Monitoring

Blood glucose (steroid-induced DM screening)
Blood pressure
BMD (DEXA scan) at baseline if >3 months anticipated
Potassium
Intraocular pressure (long-term)
Growth (children)

Reference: BNFc; BNF 90; NICE CG146 (Glucocorticoid-induced Osteoporosis); BTS/SIGN British Guideline on Asthma. Verify against your local formulary and the latest BNF before prescribing.

Curated clinical cross-links plus same-class fallbacks.

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