Metcort Dosage/Direction for Use

Complications of corticosteroid treatment are highly variable between patients as are durations of treatment. Dose, duration and mode (daily or intermittent) of treatment should be individually determined based on assessment of risk/benefit.
The lowest effective corticosteroid dose should be used to control the condition being treated. Gradual reduction of dosage is recommended whenever possible.
Dosage should be individualized based on the condition being treated and the patient's response. Maintain and/or adjust initial dosage until a satisfactory response is noted. Discontinue methylprednisolone and shift the patient to other appropriate therapy if clinical response is unsatisfactory after a reasonable period of time. Constant monitoring is needed as regard to dosage. Situations which make dosage adjustments necessary include changes in clinical status secondary to remissions or exacerbations in the disease process; the patient's individual drug responsiveness and the effect of patient exposure to stressful situations not directly related to the disease entity under treatment; it may be necessary to increase the dosage of methylprednisolone for a period of time consistent with the patient's condition.
Recommended Dose: Usual Initial Dose: 4-48 mg/day given in 4 divided doses depending on the specific disease being treated. However, initial doses of up to ≥100 mg may be used in acute severe disease.
The initial suppressive dose level may vary depending on the condition being treated. This is continued until a satisfactory clinical response is obtained, a period usually of 3-7 days in the case of rheumatic disease (except for acute rheumatic carditis), allergic conditions affecting the skin or respiratory tract and ophthalmic diseases. Re-evaluate the case to confirm the original diagnosis if a satisfactory response is not achieved in 7 days. Upon obtaining a satisfactory response, decrease dose in small increments (not >2 mg at intervals of 7-10 days are suggested) either to terminate treatment in the case of acute conditions (ie, seasonal asthma, exfoliative dermatitis, acute ocular inflammations) or until the lowest level that maintains an adequate clinical response is reached in chronic conditions (ie, RA, systemic lupus erythematosus, bronchial asthma, atopic dermatitis).
Clinical situations which may require high dose therapy of corticosteroids eg, multiple sclerosis, cerebral edema and organ transplantation should maintain initial dosage or adjust until a satisfactory response is observed in the patient. Discontinue methylprednisolone and shift the patient to other appropriate therapy if clinical response is unsatisfactory after a reasonable period of time. If there is a lack of satisfactory clinical response after a reasonable period of time, discontinue methylprednisolone and transfer patient to other appropriate therapy. If after long-term therapy the drug is to be stopped, it is recommended that methylprednisolone be discontinued gradually rather than abruptly.
Suggested Initial Daily Methylprednisolone Dose (Given Either as Single Dose or in Divided Doses): Rheumatoid Arthritis: Severe: 12-16 mg; Moderately Severe: 8-12 mg; Moderate: 4-8 mg. Children: 4-8 mg.
Systemic Dermatomyositis: 48 mg.
Systemic Lupus Erythematosus: 20-100 mg.
Acute Rheumatic Fever: 48 mg until ESR normal for 1 week.
Allergic Diseases: 12-40 mg.
Bronchial Asthma: Up to 64 mg single dose/alternate day up to maximum of 100 mg.
Ophthalmic Diseases: 12-40 mg.
Hematological Disorders and Leukemias: 16-100 mg.
Malignant Lymphoma: 16-100 mg.
Ulcerative Colitis: 16-60 mg.
Crohn's Disease: Up to 48 mg/day in acute episodes.
Organ Transplantation: Up to 3.6 mg/kg/day.
Pulmonary Sarcoid: 32-42 mg on alternate days.
Giant Cell Arteritis/Polymyalgia Rheumatica: 64 mg.
Pemphigus Vulgaris: 80-360 mg.
Multiple Sclerosis: 200 mg/day.
Cerebral Edema: 200-1,000 mg/day.
Treatment of Acute Exacerbations of Multiple Sclerosis: 200 mg/day of prednisolone for 1 week followed by 80 mg every other day for 1 month have been shown to be effective (4 mg of methylprednisolone is equivalent to 5 mg of prednisolone).
Renal Impairment: There is no dosing adjustment recommended in patients with renal insufficiency.
Children: Methylprednisolone treatment should be based on severity of the condition and response of the patient more than by age, body weight or body surface area. Dosage should be decreased in small decrements to the lowest level that maintains an adequate clinical response after a satisfactory response is obtained. The range of initial doses is 0.117-1.66 mg/kg/day (3.3-50 mg/m² body surface area/day) given in 3 or 4 divided doses.
Alternate Day Therapy (ADT): Alternate day therapy is a corticosteroid dosing regimen in which twice the usual daily dose of corticosteroid is administered every other morning. The rationale of this dosing regimen is for patients requiring long-term pharmacologic dose treatment to receive the beneficial effects of glucocorticoids while minimizing certain adverse effects (eg, pituitary-adrenal suppression, Cushingoid state, glucocorticoid withdrawal symptoms, growth suppression in children). This rationale is based on 2 major premises: The anti-inflammatory or therapeutic effect of glucocorticoids persists longer than their physical presence and metabolic effects, and administration of the corticosteroid every other morning allows for re-establishment of more nearly normal hypothalamic-pituitary-adrenal (HPA) activity on the off-corticosteroid day.
When considering ADT, the following should be kept in mind: Basic principles and indications for corticosteroid therapy should apply. The benefits of ADT should not encourage the indiscriminate use of corticosteroids.
This is usually recommended in patients who require long-term pharmacologic dose corticosteroid treatment.
It may be possible to initiate treatment with ADT in less severe cases in which corticosteroid therapy is indicated. More severe disease states will usually require daily divided high dose therapy for initial control of the disease. The initial suppressive dose level should be continued until satisfactory clinical response is obtained (usually 4-10 days in the case of many allergic and collagen diseases). It is important to keep the period of initial suppressive dose as brief as possible, particularly when subsequent use of ADT is intended. Once control has been established, either of these 2 regimens maybe utilized: Change to ADT and then gradually reduce the amount of corticosteroid given every other day or following control of the disease process, reduce the daily dose of corticosteroid to the lowest effective level as rapidly as possible and then change over to an ADT. Theoretically, the former regimen may be preferable.
Patients who have been on daily corticosteroids for long periods of time (eg, patients with RA) may already have suppressed HPA axis and establishing them on ADT may be difficult and not always successful. However, it is recommended that regular attempts be made to change them over to ADT. It may be helpful to triple or even quadruple the daily maintenance dose and administer this every other day rather than just doubling the daily dose. Once the patient is again controlled, an attempt should be made to reduce this dose to a minimum.
Certain corticosteroids (eg, dexamethasone and betamethasone) are not recommended for ADT because of their prolonged suppressive effect on adrenal activity.
The maximal activity of the adrenal cortex is between 2:00 am and 8:00 am and it is minimal between 4:00 pm and midnight. Exogenous corticosteroids suppress adrenocortical activity the least, when given at the time of maximal activity (am).
It is important to individualize and tailor the therapy to each patient when using ADT. Complete control of symptoms will not be possible in all patients. An explanation of the benefits of ADT will help the patient understand and tolerate the possible flare-up in symptoms which may occur in the latter part of the off-corticosteroid day. Other symptomatic therapy may be added or increased at this time if needed.
It may be necessary to return to a full suppressive daily divided corticosteroid dose for control in the event of an acute flare-up. ADT may be reinstituted once control is re-established.
Although many of the adverse effect of corticosteroids may be minimized by ADT, the physician must carefully weigh the benefit risk ratio for each patient in whom corticosteroid therapy is considered.