NHS Greater Glasgow & Clyde Area Drug and Therapeutics Committee
Greater Glasgow and Clyde Medicines
Medicines Update Acute

New prednisolone tablet strengths: risk of error

Prednisolone is now also available as 10 mg and 20 mg strength tablets.  These are welcomed additions to the current range of prednisolone formulations (1mg, 2.5mg, 5mg and 25mg) but may cause some initial confusion.  The scenarios below demonstrate the potential for accidental overdose or sub-therapeutic dose:

 

  • GP prescribes 40 mg daily of prednisolone for a patient with an acute exacerbation of COPD.  The 20 mg strength is prescribed and labelled as ‘take TWO tablets daily’.  The patient, who is regularly prescribed EIGHT 5 mg strength tablets daily for an exacerbation, is not informed of the change of strength and takes EIGHT 20 mg strength tablets.
  • Patient is admitted to hospital and informs the receiving medic that she takes two prednisolone tablets daily for long term treatment of RA.  The tablet strength is assumed to be 5 mg and a dose of 10 mg daily is prescribed on the medicine chart. As the patient had been prescribed the new 10 mg strength tablet her actual dose on admission was 20 mg daily.

 

Advice for medical, nursing and pharmacy staff

  • When undertaking Medicines Reconciliation, use a minimum of two sources to confirm the strength of prednisolone tablets.
  • Double check strength of prednisolone tablets when choosing from drop-down lists on electronic prescribing systems.
  • Double check choice of prednisolone tablets when administering or dispensing oral prednisolone. The tablets and packaging may be very similar.
  • Highlight any change of tablet strength to the patient or carer and any resultant change to the number of tablets to be taken.
  • Report any incidents via DATIX.