Steroid Conversion
Below are approximate equivalent synthetic steroid doses (administered by the oral or IV routes), and their relative glucocorticoid and mineralocorticoid potencies.
When charting the same, ensure appropriate administration intervals and check with local protocols and your pharmacist colleagues regarding the same (e.g. 50 mg daily of prednisone po, would be equivalent to 50 mg 6 hourly of hydrocortisone IV, or 200 mg IV daily).
| Agent | Equivalent dose (mg) | Anti-inflammatory potency | Mineralocorticoid potency | DoA |
| Cortisone | 25 | 0.8 | 0.8 | Short |
| Hydrocortisone | 20 | 1 | 1 | Short |
| Prednisone | 5 | 4 | 0.3 | Intermediate |
| Prednisolone | 5 | 4 | 0.3 | Intermediate |
| Triamcinolone | 4 | 5 | 0 | Intermediate |
| Methylprednisolone | 4 | 5 | 0.25 | Intermediate |
| Betamethasone | 0.6 | 25-40 | 0 | Long |
| Dexamethasone | 0.75 | 25 | 0 | Long |
| Fludrocortisone* | 2 | 10* | 250 | Intermediate |
Duration of Action (DoA)
- Short: 8-12 hours
- Intermediate: 12-36 hours
- Long: 36-72 hours
In reality, even after plasma levels fall, anti-inflammatory and immunosuppressive effects can last hours to days. This is because these steroid effects result from alterations in gene transcription and protein translation, and will persist until the protein products degrade.
Example
Conversion of hydrocortisone 50mg q6h IV to prednisolone daily:
- Starting point: Hydrocortisone q6h at 50 mg per dose → 4 doses/day = 200 mg hydrocortisone daily.
- Conversion ratio: 4:1 (hydrocortisone 20mg : prednisolone 5mg).
- So:
References and Links
Introduction to ICU Series
Introduction to ICU Series Landing Page
DAY TO DAY ICU: FASTHUG, ICU Ward Round, Clinical Examination, Communication in a Crisis, Documenting the ward round in ICU, Human Factors
AIRWAY: Bag Valve Mask Ventilation, Oropharyngeal Airway, Nasopharyngeal Airway, Endotracheal Tube (ETT), Tracheostomy Tubes
BREATHING: Positive End Expiratory Pressure (PEEP), High Flow Nasal Prongs (HFNP), Intubation and Mechanical Ventilation, Mechanical Ventilation Overview, Non-invasive Ventilation (NIV)
CIRCULATION: Arrhythmias, Atrial Fibrillation, ICU after Cardiac Surgery, Pacing Modes, ECMO, Shock
CNS: Brain Death, Delirium in the ICU, Examination of the Unconscious Patient, External-ventricular Drain (EVD), Sedation in the ICU
GASTROINTESTINAL: Enteral Nutrition vs Parenteral Nutrition, Intolerance to EN, Prokinetics, Stress Ulcer Prophylaxis (SUP), Ileus
GENITOURINARY: Acute Kidney Injury (AKI), CRRT Indications
HAEMATOLOGICAL: Anaemia, Blood Products, Massive Transfusion Protocol (MTP)
INFECTIOUS DISEASE: Antimicrobial Stewardship, Antimicrobial Quick Reference, Central Line Associated Bacterial Infection (CLABSI), Handwashing in ICU, Neutropenic Sepsis, Nosocomial Infections, Sepsis Overview
SPECIAL GROUPS IN ICU: Early Management of the Critically Ill Child, Paediatric Formulas, Paediatric Vital Signs, Pregnancy and ICU, Obesity, Elderly
FLUIDS AND ELECTROLYTES: Albumin vs 0.9% Saline, Assessing Fluid Status, Electrolyte Abnormalities, Hypertonic Saline
PHARMACOLOGY: Drug Infusion Doses, Summary of Vasopressors, Prokinetics, Steroid Conversion, GI Drug Absorption in Critical Illness
PROCEDURES: Arterial line, CVC, Intercostal Catheter (ICC), Intraosseous Needle, Underwater seal drain, Naso- and Orogastric Tubes (NGT/OGT), Rapid Infusion Catheter (RIC)
INVESTIGATIONS: ABG Interpretation, Echo in ICU, CXR in ICU, Routine daily CXR, FBC, TEG/ROTEM, US in Critical Care
ICU MONITORING: NIBP vs Arterial line, Arterial Line Pressure Transduction, Cardiac Output, Central Venous Pressure (CVP), CO2 / Capnography, Pulmonary Artery Catheter (PAC / Swan-Ganz), Pulse Oximeter
LITFL
- Basic Science – Pharm 101: Corticosteroids
- CCC – Corticosteroids Overview
- CCC – Steroids and Septic Shock Literature Summaries
- CCC – Adrenal Insufficiency
References
- Brunton LL, Hilal-Dandan R, Knollmann BC, eds. Goodman & Gilman’s: The Pharmacological Basis of Therapeutics. 13th ed. New York, NY: McGraw-Hill Education; 2018.
- MDCalc — Steroid Conversion Converter
- Liu D, Ahmet A, Ward L, Krishnamoorthy P, Mandelcorn ED, Leigh R, Brown JP, Cohen A, Kim H. A practical guide to the monitoring and management of the complications of systemic corticosteroid therapy. Allergy Asthma Clin Immunol. 2013 Aug 15;9(1):30. doi: 10.1186/1710-1492-9-30. PMID: 23947590; PMCID: PMC3765115.
- Meikle AW, Tyler FH. Potency and duration of action of glucocorticoids. Effects of hydrocortisone, prednisone and dexamethasone on human pituitary-adrenal function. Am J Med. 1977 Aug;63(2):200-7. doi: 10.1016/0002-9343(77)90233-9. PMID: 888843.
- Vanderah, T. W., & Katzung, B. G. (2024). Katzung’s Basic and Clinical Pharmacology (16th ed.). McGraw-Hill Education.
Critical Care
Compendium
Chris is an Intensivist and ECMO specialist at The Alfred ICU, where he is Deputy Director (Education). He is a Clinical Adjunct Associate Professor at Monash University, the Lead for the Clinician Educator Incubator programme, and a CICM First Part Examiner.
He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives. He was one of the founders of the FOAM movement (Free Open-Access Medical education) has been recognised for his contributions to education with awards from ANZICS, ANZAHPE, and ACEM.
His one great achievement is being the father of three amazing children.
On Bluesky, he is @precordialthump.bsky.social and on the site that Elon has screwed up, he is @precordialthump.
| INTENSIVE | RAGE | Resuscitology | SMACC
ICU Provisional Fellow BMedSci [Newcastle], BMed [Newcastle], MMed(CritCare) [Sydney] from a broadacre farm who found himself in a quaternary metropolitan ICU. Always trying to make medical education more interesting and appropriately targeted; pre-hospital and retrieval curious; passionate about equitable access to healthcare; looking forward to sitting on a tractor at harvest time. Student of LITFL.
5 Comments
Leave a Reply
This site uses Akismet to reduce spam. Learn how your comment data is processed.
Isn’t 5 mg of pred equivalent to (20 mg hydrocortisone QID)?
Hi DH,
Not according to our sources (see in the references). 5mg of prednisone would be equivalent to 5mg QID of hydrocortisone — a total dose of 20mg. Keep in mind that we need to dose with an appropriate interval for the hydrocortisone due to a shorter half-life to have a similar effect over a similar amount of time. 20mg QID of hydrocortisone (or 80mg a day) would be equivalent to 20mg daily of prednisone.
Thanks,
James
Usually the daily dose is converted, and then the frequency of adminstration is accounted for – so 5mg prednisone po daily is 20mg hydrocortisone IV daily, which is 5mg hydrocortisone IV 4 times a day.
If hydrocortisone has an effective duration of action of 8-12 hours as in your MD Calc referrence, if you gave hydrocortisone 5 mg QID, after 12 hours the first 5 mg you gave is no longer acting? At 24 hours, the first 2 doses are no longer acting. Meaning essentially at any one time there is only the last 12 hours of hydocortisone actually doing anything. So 5 mg QID hydrocortisone means at any one time, 10 mg of hydrocortisone is working, rather than 20 mg.
Therefore do we not compare this to the amount of prednisone, which has a duration of action of 12 to 36 hours, that is actually active, at any one time of the day, which in this case would be 2.5 mg? 5 mg every 6 hours of hydrocortisone IV means 10 mg hydrocortisone actually working at any one time = 2.5 mg prendisone daily?
Hi
There will be differences in the instantaneous effects but the rationale for clinical conversions use being based on total daily dose equivalence is due to:
– Genomic effects accumulate and taper slowly.
– Anti-inflammatory and immunosuppressive outcomes are more dependent on cumulative exposure then instantaneous effects.
It is appropriate to use a larger initial dose of hydrocortisone (e.g. on ICU admission) if converting from prednisolone in a sick patient, then reverting to the total daily equivalence approach.
e.g.
Bornstein SR et al. “Diagnosis and Treatment of Primary Adrenal Insufficiency: An Endocrine Society Clinical Practice Guideline.” J Clin Endocrinol Metab. 2016;101(2):364–389.
Recommends stress-dose hydrocortisone (100 mg IV bolus, then 50 mg q6h) for adrenal crisis or major stress, especially when transitioning from longer-acting steroids.