Steroid converter

Equivalent dose, glucocorticoid (GC) potency, biological half-life: ESE/ES 2024 Table 1. Its footnotes: estimates from historically accepted conversion factors, a guide only; apply to oral and/or IV administration; mineralocorticoid effects not considered.

Dexamethasone and betamethasone: the 2024 guideline lists 0.5 mg ≈ hydrocortisone 20 mg. Older tables (Liu 2013 / NICE) use 0.75 mg dexamethasone and 0.6 mg betamethasone. The tool shows both, as a range, because the choice changes the dose by 50%.

Mineralocorticoid (MC) potency (Na⁺ retention per mg relative to hydrocortisone): Parente 2017 Table 1, from Goodman & Gilman. Liu 2013 lists methylprednisolone and dexamethasone as "minimal" and betamethasone as "negligible". *Fludrocortisone: duration of action, Liu 2013.

Risk is expected when oral exposure exceeds both thresholds: duration ≥3–4 weeks and dose above the physiologic daily dose equivalent — hydrocortisone 15–25 mg, prednisone/prednisolone 4–6 mg, methylprednisolone 3–5 mg, dexamethasone 0.25–0.5 mg. Cortisone and betamethasone are compared through their hydrocortisone equivalent.

• R2.1 — therapy <3–4 weeks: no taper or testing needed for HPA reasons, irrespective of dose.
• R2.2 / Table 4 — taper only once the underlying disease is controlled: >40 mg prednisone, 5–10 mg/week; 20–40 mg, 5 mg/week; 10–20 mg, 2.5 mg every 1–4 weeks; 5–10 mg, 1 mg every 1–4 weeks; at 5 mg, 1 mg every 4 weeks if no symptoms (or switch to hydrocortisone 20 mg, reducing by 5 mg).
• R2.5 — switch long-acting agents (dexamethasone, betamethasone) to shorter-acting ones once no longer needed.
• R2.6–2.7 — at a physiologic dose: keep tapering with clinical monitoring, or check 8–9 am cortisol: >10 µg/dL (300 nmol/L) recovery; 5–10 µg/dL (150–300) continue and repeat in weeks–months; <5 µg/dL (150) continue and repeat in a few months. The cut-offs are rounded, not exact conversions, and assay-dependent. The tool classifies the value in the unit you typed it in, so the band does not flip when you switch units, and it takes the more cautious band when display rounding crosses a cut-off.
• R2.9 — consider adrenal insufficiency with non-oral steroids: multiple formulations, high-dose inhaled or topical, inhaled/topical >1 year, intra-articular injection in the last 2 months, strong CYP3A4 inhibitors.
• R2.11 — no recovery after 1 year on a physiologic dose, or any adrenal crisis: refer to endocrinology. R2.12 — no fludrocortisone in glucocorticoid-induced adrenal insufficiency (aldosterone is preserved).

For patients with current or recent glucocorticoid use who have not been tested to exclude adrenal insufficiency (R3.1). Oral for minor stress; parenteral for moderate–major stress, general or regional anesthesia, prolonged NPO, vomiting/diarrhea, or hemodynamic instability.

• Minor illness: no increase needed if already on ≥40 mg hydrocortisone, ≥10 mg prednisone or ≥1 mg dexamethasone daily. Otherwise hydrocortisone 40 mg/day (20 mg on rising, 10 mg midday, 10 mg 5 pm), prednisone 10 mg/day, or dexamethasone 1 mg daily, for 2–5 days until well or for the course of antibiotics. Other agents: the equivalent of hydrocortisone 40 mg.
• Moderate–major stress: no increase needed if already on ≥200 mg hydrocortisone, ≥50 mg prednisone or ≥6–8 mg dexamethasone daily (the tool uses the 8 mg end; betamethasone and other agents are compared by hydrocortisone equivalent on the lower, classic factor). Otherwise hydrocortisone 100 mg IV/IM, then 200 mg/24 h by continuous infusion (or 50 mg IV every 6 h).
• After surgery: double the oral dose for 48 h (hydrocortisone 40 mg/day, prednisone 10 mg/day or dexamethasone 1 mg/day), then the pre-surgical dose.
• Adrenal crisis: hydrocortisone 100 mg IV/IM immediately with rapid 0.9% saline, then 200 mg/24 h (continuous IV preferred, or 50 mg every 6 h) until recovery. Do not wait for labs. Consider higher doses with very high body weight.

The guideline notes these regimens rest on clinical practice, not head-to-head trials, and lower doses are used in some centers.

• Equivalence tables are approximate. Individual metabolism varies (for example, about 20% of people clear methylprednisolone faster), and older adults clear steroids more slowly.
• Mineralocorticoid effect does not follow glucocorticoid equivalence. Going from hydrocortisone to dexamethasone or methylprednisolone removes most of the sodium-retaining effect. This matters in primary adrenal insufficiency, not in glucocorticoid-induced (secondary) insufficiency.
• Dexamethasone is long-acting and very potent. Even at physiologic-equivalent doses it suppresses the HPA axis more, and recovery cannot occur while it is given continuously.
• Glucocorticoid withdrawal symptoms during a taper can mimic adrenal insufficiency. Insufficiency is unlikely while the total dose is still supraphysiologic, except in critical illness or when absorption fails (gastroenteritis).