Steroid Dose
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Corticosteroid Equivalence Reference Table

Key Clinical Notes

• Prednisolone vs Prednisone: Prednisone is converted to prednisolone in the liver. They are clinically interchangeable for most patients. Prednisolone is preferred in severe hepatic impairment (bypasses hepatic conversion)
• Dexamethasone has no mineralocorticoid activity: Does NOT cause sodium/water retention. Preferred when oedema is a concern, or in patients with hypertension or heart failure needing high-dose steroids. Also preferred for brain oedema, pre-term lung maturation, and COVID-19 (RECOVERY trial)
• Hydrocortisone has strong mineralocorticoid activity: Used for physiological replacement in adrenal insufficiency. 20 mg hydrocortisone = daily cortisol production. At stress doses (200–300 mg/day) it provides both glucocorticoid AND mineralocorticoid cover in septic shock
• Methylprednisolone IV: No mineralocorticoid activity, rapid onset, widely used for acute severe asthma (1–2 mg/kg/day), ARDS, MS relapse (1g IV × 3 days), spinal cord injury (controversial), organ rejection prophylaxis
• Budesonide (oral, e.g. Budecort): High first-pass metabolism means 90% is inactivated by liver — much lower systemic exposure than equivalent prednisolone dose. Used in Crohn's disease, microscopic colitis, and as bridge therapy

Steroid Tapering — Preventing Adrenal Insufficiency

• HPA axis suppression occurs after approximately 3 weeks of any dose equivalent to prednisolone ≥5 mg/day, or any dose of dexamethasone for >1 week
• Taper rule of thumb: reduce by 10–20% of total dose every 1–2 weeks once the underlying condition is controlled. Slower taper as you approach physiological doses
• Physiological dose: prednisolone 5 mg/day = approximately 20 mg hydrocortisone/day. Do NOT stop abruptly at this dose — continue until morning cortisol/short Synacthen test confirms HPA recovery
• Sick day rules: patients on long-term steroids should double or triple their dose during acute illness, surgery, or trauma to prevent Addisonian crisis
• Stress doses (surgery/critical illness): IV hydrocortisone 200 mg/day continuous infusion, or 50 mg QID, for major surgery. Can switch to oral as soon as patient tolerating

Frequently Asked Questions

What is steroid equivalence?

Steroid equivalence refers to the anti-inflammatory potency of different corticosteroids relative to hydrocortisone (reference = 1). Equivalent anti-inflammatory doses: hydrocortisone 20 mg = prednisolone 5 mg = methylprednisolone 4 mg = dexamethasone 0.75 mg = betamethasone 0.6 mg. Note: mineralocorticoid potency is separate — dexamethasone has negligible mineralocorticoid activity while hydrocortisone has significant fludrocortisone-like effects.

What is the difference between prednisolone and dexamethasone?

Prednisolone: moderate potency (4–5x hydrocortisone), significant mineralocorticoid activity, half-life 12–36 hours, once or twice daily dosing, first-line for most chronic inflammatory conditions. Dexamethasone: high potency (25–30x hydrocortisone), negligible mineralocorticoid activity, half-life 36–72 hours, once daily dosing, preferred for: brain oedema, COVID-19 (RECOVERY trial), antenatal lung maturation, croup, antiemesis (chemotherapy), and acute spinal cord compression.

How should long-term steroids be tapered?

Prolonged steroid use (>3 weeks at >5 mg prednisolone/day) suppresses the HPA axis — abrupt withdrawal can cause adrenal crisis (hypotension, hyponatraemia, hypoglycaemia, death). Taper by 10–20% every 1–2 weeks until physiological dose (prednisolone 5–7.5 mg/day), then slower taper. Physiological steroid dose is approximately prednisolone 5 mg/day (equivalent to cortisol production of 15–20 mg/day). Check morning cortisol before stopping completely.

What are the side effects of long-term steroid use?

Metabolic: hyperglycaemia (steroid-induced DM), hyperlipidaemia, weight gain, moon face, buffalo hump, central obesity. Musculoskeletal: osteoporosis (DEXA scan + bisphosphonate prophylaxis if >3 months use), myopathy (proximal weakness — characteristic). Cardiovascular: hypertension, fluid retention. GI: peptic ulcer disease (especially with NSAIDs — PPI prophylaxis). Ophthalmic: posterior subcapsular cataracts, raised IOP/glaucoma. Endocrine: HPA suppression, growth retardation in children. Infection: increased susceptibility, reactivation of TB/strongyloides.

When are steroids used in critical care?

Evidence-based ICU indications: septic shock refractory to vasopressors (hydrocortisone 200 mg/day IV — APROCCHSS trial), ARDS (dexamethasone 20 mg/day × 5 days then 10 mg × 5 days — DEXA-ARDS trial), COVID-19 requiring O2/ventilation (dexamethasone 6 mg/day × 10 days — RECOVERY trial), meningitis (dexamethasone 0.15 mg/kg QID × 4 days — reduces hearing loss in pneumococcal meningitis), anaphylaxis (hydrocortisone 200 mg IV), and acute spinal cord injury (controversial).

What steroid is used for antenatal lung maturation?

Betamethasone 12 mg IM × 2 doses 24 hours apart (or dexamethasone 6 mg IM × 4 doses 12 hours apart) given to the mother at 24–34 weeks gestation when preterm delivery is anticipated within 7 days. Reduces neonatal RDS, IVH, necrotising enterocolitis, and neonatal mortality by 30–50%. A single course is recommended — repeated courses (>2) are associated with reduced fetal growth and neurodevelopmental risk.

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