PHARMACOKINETICS AND PHARMACODYNAMICS

ARTICLE
MAGER
10.1177/0091270003258651
DOSE
PHARMACOKINETICS
EQUIVALENCY
ET AL EVALUATION
AND PHARMACODYNAMICS
OF CORTICOSTEROIDS

Dose Equivalency Evaluation of Major

Corticosteroids: Pharmacokinetics and
Cell Trafficking and Cortisol Dynamics
Donald E. Mager, PharmD, PhD, Sheren X. Lin, PharmD,
Robert A. Blum, PharmD, Christian D. Lates, MD, and William J. Jusko, PhD

The integrity of current corticosteroid dose equivalency ta-
bles, as assessed by mechanistic models for cell trafficking
and cortisol dynamics, was investigated in this study. Single,
presumably equivalent, doses of intravenous hydrocortisone,
methylprednisolone, dexamethasone, and oral prednisolone
were given to 5 white men, according to total body weight, in a
5-way crossover, placebo-controlled study. Pharma-
codynamic (PD) response-time profiles for T helper cells, T
suppressor cells, neutrophils, and adrenal suppression were
evaluated by extended indirect response models. For adrenal
suppression, prednisolone appears to be less potent than
methylprednisolone or dexamethasone. A good correlation
was found between the estimated in vivo EC50 values and rel-
ative receptor affinity (equilibrium dissociation constants
normalized to dexamethasone). Area under the effect curves
of all PD responses was calculated using a linear-trapezoidal
method. Although T helper cell trafficking and adrenal
suppression achieved significant differences by repeated-
measures ANOVA (p = 0.014 and 0.022), post hoc analysis
using the Bonferroni method revealed no difference between
treatments. Although limited by the use of single doses and a
relatively small sample size, this study applies mechanistic
models for several biomarkers showing that currently used
dosing tables reflect reasonable dose equivalency relation-
ships for four corticosteroids.
Keywords: Glucocorticosteroids; dose equivalency tables;
cell trafficking; pharmacokinetics
Journal of Clinical Pharmacology, 2003;43:1216-1227
©2003 the American College of Clinical Pharmacology

S ystemic glucocorticosteroids (GC) currently play a

major role as immunosuppressive agents for
diseases in which inflammation or immunologically me-
diated phenomena play a predominant pathophysiologic
role.1-5 To optimize therapy, it is not uncommon for cli-
nicians to switch from one agent of this group to an-
From the Buffalo Clinical Research Center, Buffalo, New York (Dr. Lin, Dr.
Blum, Dr. Lates) and the Department of Pharmaceutical Sciences, School
of Pharmacy and Pharmaceutical Sciences, University at Buffalo, State
University of New York, Buffalo, New York (Dr. Mager, Dr. Jusko). Sup-
ported by grant GM24211 to Dr. Jusko from the National Institutes of
General Medical Sciences (National Institutes of Health); fellowship sup-
port for Dr. Lin from GlaxoSmithKline Pharmaceuticals, Philadelphia; and
a predoctoral fellowship for Dr. Mager from the American Foundation for
Pharmaceutical Education. Submitted for publication March 3, 2003; re-
vised version accepted August 10, 2003. Address for reprints: William J.
Jusko, PhD, Department of Pharmaceutical Sciences, School of Pharmacy
and Pharmaceutical Sciences, University at Buffalo, State University of
New York, Buffalo, NY 14260.
DOI: 10.1177/0091270003258651
other. One of the problems encountered in the usage of
systemic GC is the integrity of dose equivalency tables.
Most equivalency tables used today have been derived
from clinical experience and older literature. Currently
acceptable equivalent doses for the major systemic GC
are hydrocortisone (20 mg), prednisolone (5 mg),
methylprednisolone (4 mg), and dexamethasone
(0.75 mg).5 Although traditional pharmacokinetic/
pharmacodynamic (PK/PD) models have been applied
to characterize the major effects of steroids in the con-
text of dose equivalency,6 such assessments using more
contemporary mechanistic PK/PD models to follow the
potency of several immunosuppressive effects have yet
to be performed.
The precise mechanisms of action of GC still remain
elusive.7-9 Suggested mechanisms include the inhibi-
tion of specific cellular functions and cellular redistri-
bution of lymphocytes and neutrophils.7 Lymphocytes
normally migrate between blood and tissue, which al-
lows the immune system to react to antigens through-

1216 • J Clin Pharmacol 2003;43:1216-1227

 DOSE EQUIVALENCY EVALUATION OF CORTICOSTEROIDS
out the body.10,11 The GC transiently deplete lympho-
cytes from the circulation, and T helper and T
suppressor cells, in particular, are more sensitive to
this effect.12,13 Lymphocytes kept out of circulation
have less access to the target organs in which they exert
their effects.14 The characterization of lymphocyte dy-
namics is therefore important for understanding the
effect of GC on the immune system.
The rise in neutrophil count following GC exposure
is thought to be due to accelerated release from the
bone marrow and reduced movement out of the blood
into inflammatory sites.14 In the presence of inflamma-
tion, the migration of neutrophils from blood to areas of
inflamed tissues is an essential step in the inflamma-
tory process. Evidence suggests that, in patients with
chronic inflammatory conditions, the accumulation of
neutrophils in the blood is due to the effect of GC on the
adhesion properties of neutrophils.15 It is uncertain
whether this process plays a significant role in the
neutrophilia seen in subjects not experiencing an in-
flammatory event; we therefore have assessed
neutrophil dynamics in blood.
The primary purpose of this study is to further char-
acterize and compare the immunosuppressive and
anti-inflammatory properties of four systemic GC—
hydrocortisone, prednisolone, methylprednisolone,
and dexamethasone—at currently accepted equivalent
doses. This was approached by assessing T helper, T
suppressor, and neutrophil cell trafficking using mech-
anistic dynamic models. One of the major limitations
of using systemic GC is their ability to suppress the re-
lease of corticotropin from the pituitary, thus decreas-
ing the secretion of cortisol by the adrenal cortex.7,16 A
secondary goal of this study was to compare the rela-
tive potency of adrenal suppression among the four
systemic GC.
METHODS
Subjects
Five healthy male volunteers were recruited to partici-
pate in this study. All subjects were 23 to 40 years of age
(mean ± SD, 32.2 ± 7.6 years), were within 25% of ideal
body weight (73.6 ± 10.7 kg), and had a normal circa-
dian rhythm (nightshift workers were excluded). All
subjects were determined to be healthy by assessment
of medical history, physical examination, EKG, blood
chemistry, and hematologic profile. Creatinine clear-
ances averaged 98.9 ± 18.4 mL/min. None of the sub-
jects had a documented allergy to corticosteroids, and
none were receiving any concurrent medications
PHARMACOKINETICS AND PHARMACODYNAMICS
known to alter the metabolism of corticosteroids. All
volunteers were prohibited from using any prescrip-
tion or over-the-counter medications (with exception
for acetaminophen ≤ 2 g/day and vitamins) within 14
days prior to each of the study periods. Alcohol and
beverages containing caffeine or xanthine derivatives
were not permitted for 24 hours prior to the start of each
period until the end of each 32-hour blood collection
period. This study was approved by the Kaleida Health
Millard Fillmore Hospital Institutional Review Board
(Buffalo, NY) and performed in accordance with the
Declaration of Helsinki. All subjects were informed of
the nature, purposes, and risks of the study and
provided informed consent.
Procedure
This was a single-dose, randomized, five-period cross-
over study with placebo control. It was single blinded,
with all subjects confined in the Buffalo Clinical Re-
search Center during all five periods of the study to
control for identical eating and sleeping patterns. The
confinement period was approximately 34 hours dur-
ing each period, beginning with dosing at 8 a.m. and
ending with the 32-hour blood draw. Each period was
separated by a 2-week washout. Dosing was according
to total body weight (TBW) of each subject based on Ta-
ble I. During each period, subjects received a single
dose of intravenous hydrocortisone (hydrocortisone
sodium succinate, Solu-Cortef ® , Pharmacia),
methylprednisolone (methylprednisolone sodium
succinate, Solu-Medrol®, Pharmacia), dexamethasone
(dexamethasone phosphate, Decadron®, Merck), oral
prednisolone (generic prednisolone tablets, Schein), or
saline injection for placebo control.
On day 1 of each study period, two 18-gauge
angiocatheters were inserted into veins of both arms to
facilitate drug dosing and blood sample collections.
The catheter for drug administration was promptly re-
moved after dosing, and the remaining catheter was
kept patent with the use of a dilute heparin solution (10
units/mL). Samples of approximately 7 mL of blood
were drawn into heparin-containing collection tubes
for drug analysis. The blood samples were centrifuged
at 2000 rpm for 15 minutes, and plasma was harvested
and frozen at –20°C until assayed. In addition, 3-mL
blood samples were drawn into EDTA-containing
tubes for the determination of cell counts. These sam-
ples were kept at room temperature and the assays per-
formed within 12 hours. All blood samples were col-
lected at 0, 0.5, 1, 1.5, 2, 4, 8, 12, 16, 24, 28, and 32 hours
after dosing.
1217
 MAGER ET AL

Table I Dosages (mg) of Study Drugs

a
Weight Range Hydrocortisone Prednisolone Methylprednisolone Dexamethasone

50-59 kg 110 28 22 4
60-69 kg 130 32 25 5
70-79 kg 150 38 30 6
80-89 kg 170 42 34 6.5
90-100 kg 185 46 36 7
a. Based on total body weight.

Bioanalysis Pharmacokinetics

Plasma Glucocorticoid Concentrations Prednisolone

Corticosteroid concentrations were determined using
the normal-phase high-performance liquid chromatog-
raphy (HPLC) procedure of Rose and Jusko,17 as revised
by Jusko et al.18 The lower limit of detection was 5.0 ng/
mL for all steroids, and both the interday coefficients of
variation (CV) and percent error were ≤ 13%. Samples
falling below the limit of detection were excluded from
data analysis, except for cortisol, which was set equal
to half the limit of quantification owing to expecta-
tions of its continual presence. Plasma protein
binding of prednisolone was determined by
ultrafiltration using the Amicon Centrifree Device, as
previously reported.19
Cell Responses
Complete leukocyte counts and differentials were ob-
tained using an automated hemocytometer (CELL-
DYN 1700, Abbott Laboratories, Abbott Park, IL). Total
lymphocyte and segmented neutrophil counts were
obtained. The T helper and T suppressor cell counts
were obtained by measuring fluorescence after per-
forming immunoreaction of lymphocytes with anti-
CD3, anti-CD4, and anti-CD8 antibodies. Whole-blood
samples (50 µL) with mouse IgG were reacted with
mouse anti-CD4 and anti-CD8 monoclonal antibody
conjugated with fluorescein isothiocyanate and
phycoerythrin for 15 minutes. After lysing and wash-
ing, samples were analyzed for T helper (CD4+:CD8–)
and T cytotoxic (CD4+:CD8+) cells using a FACScan
flow cytometer (Becton-Dickinson, Mountain View,
CA). The T helper cells were CD3+ and CD4+, whereas T
suppressor cells were CD3+ and CD8+. The total num-
ber of T helper and T suppressor cells was obtained by
multiplying the respective proportion of fluorescent
cells generated and the total number of lymphocytes.
The PK of free prednisolone were described by a one-
compartment model with first-order absorption and
elimination rate constants (ka and kel) according to the
following:
D • ka
CP =
(Vd / F)(ka − kel )
[
• e− k el • t − e− k a • t ,] (1)
where Cp represents the mean plasma concentration of
free prednisolone, D is the dose administered, and Vd/F
is the apparent volume of distribution.
Methylprednisolone
The concentrations of methylprednisolone following
an IV bolus dose were described by
D
Cp = • e− k el • t . (2)
Vd
Dexamethasone
Dexamethasone concentration-time data were de-
scribed using the following biexponential equation:
C p = C1 • e− λ 1 • t + C 2 • e− λ 2 • t . (3)
The intercept (C1, C2) and exponential coefficients (λ1,
λ2) were used to calculate kel, Vd, and the first-order dis-
tribution rate constants between the plasma and tissue
compartments (k12, k21).
Hydrocortisone
Since exogenous hydrocortisone (Chc) and endogenous
cortisol (Cen) are indistinguishable, plasma hydrocorti-
sone concentrations were estimated using a joint PK/
PD model, as shown in Figure 1. Under normal physio-
logical conditions, cortisol concentrations in the blood

1218 • J Clin Pharmacol 2003;43:1216-1227

 DOSE EQUIVALENCY EVALUATION OF CORTICOSTEROIDS

follow a circadian-episodic profile. The rate of change

of cortisol concentration (dCen/dt) can be described by a
periodic time-dependent production function, kin(t),
and the first-order elimination rate constant, kout,
according to
dC en (4)
= kin ( t ) − kout • C en .
dt

The mean baseline cortisol profile (placebo data) was

used to characterize kin(t) using Fourier analysis with
two harmonics. Mean baseline cortisol concentrations
were approximated by 24- and 12-hour period harmon-
ics. The number of harmonics was chosen based on the
percent contribution of each harmonic to the baseline
function, which was described by
 2π • nt   2π • nt 
2
C en = a 0 + ∑a
n =1
n • cos 
 24 
 + bn • sin 
 24 
, (5) Figure 1. PK/PD model of cortisol following intravenous (IV) hydro-
cortisone. Cen and Chc represent the concentrations of endogenous
and exogenous cortisol. The secretion of Cen is represented by a circa-
dian input function (kin), which is suppressed by Chc (black rectan-
where a0, a1, a2, b1, and b2 are Fourier coefficients obtained gle). The same kout value, the first-order cortisol elimination rate con-
by L2 norm approximation using FOURPHARM.20 stant, is used for Cen and Chc.
Hence, the cortisol input function, kin(t), was derived
from equations (4) and (5):
kin (t ) = kout • a 0 where C 0hc is the concentration of exogenous hydrocor-
tisone at time zero (D/Vd), and kout is the first-order
2
 b •2 π • n • t   2π • n • t 
+ ∑  kout • a n + n  • cos  + elimination rate constant. Total cortisol concentrations
n =1 
 24   24 
(Cm) can thus be defined as
(6)
 a •2 π • n • t   2π • n • t  
 kout • bn − n  • sin   .
 24   24   Cm = Chc + Cen. (10)

The PK and PD parameters were determined simulta-

The suppressive effect of GC on cortisol secretion can neously by fitting the cortisol data following hydrocor-
be characterized by an indirect response model,21 de- tisone dosing to equations (7) through (10), yielding Vd,
fined as kout, and IC50.
dC en
= kin ( t ) • I C ( t ) − kout • C en , (7)
dt Pharmacodynamics

CP Cortisol
IC (t) = 1 − , (8)
IC 50 + C p The dynamics of cortisol after methylprednisolone and
dexamethasone doses were modeled in a similar fash-
where IC(t) is the inhibition function that accounts for ion to hydrocortisone by fixing the PK parameters to
the suppression of kin by exogenous GC, Cp is the define Cp in equation (8) for each drug. The IC50 values
plasma concentrations of exogenous GC, and IC50 is the were estimated using equations (7) and (8) by fixing
concentration of exogenous GC achieving 50% inhibi- both kout and kin (equation (7)) to be the same value and
tion of cortisol secretion. function as during hydrocortisone treatment. Cortisol
The concentrations of exogenous hydrocortisone suppression by prednisolone was modeled similarly,
were represented by except kout in equation (7) was estimated. Prednisolone
is believed to displace cortisol from its binding sites in
dC hc (9)
= − kout • C hc , a concentration-dependent fashion,22 thus potentially
dt altering cortisol elimination (kout). Therefore, cortisol

PHARMACOKINETICS AND PHARMACODYNAMICS 1219


data after prednisolone treatment were fitted by equa-
tions (7) and (8) to obtain both kout and IC50.
T Helper and T Suppressor Cell Dynamics
Under normal physiological conditions, T lymphocyte
trafficking in the blood exhibits a circadian rhythm,
with migration of cells between blood and
extravascular tissue compartments.23 Endogenous
cortisol and exogenous GC inhibit the movement of
lymphocytes from the peripheral tissues to the blood.24
Therefore, the lymphocytopenia observed after GC
doses is the net result of a direct effect of the dosed GC
and influence of the endogenous GC, as shown in Fig-
ure 2. Movement of lymphocytes between the two
pools can be represented by
dEV
= − keb • I T ( t ) • EV + k be • BL,
dt
dBL
= keb • I T ( t ) • EV − k be • BL,
dt
where EV and BL represent the extravascular and
blood pools of lymphocytes, while keb and kbe are
intercompartmental rate constants. Since the total lym-
phocyte pool in the EV compartment has been esti-
mated to be 30 to 45 times that of the BL pool,25,26 equa-
tion (12) simplifies to
dBL
= kin • I T ( t ) − k be • BL,
dt
where kin = keb • EV, an apparent zero-order rate con-
stant, and IT(t) is the inhibition function related to the
GC effect on lymphocytes. The inhibitory function was
adapted from Milad et al24 and describes the joint ef-
fects of exogenous GC and endogenous cortisol:
  IC  
 C p •  50, C  + C en
  IC 50, GC 
I T (t) = 1 − 
IC  IC 50, C 
50, C + C p •   + C en
  IC 50, GC 
 
where IC50, C and IC50, GC reflect the cortisol and exoge-
nous GC concentrations that produce a 50% change in
keb. For the analysis of data collected during placebo
administration, Cp is fixed at 0.
The pharmacodynamics of lymphocyte trafficking
during hydrocortisone treatment were characterized
first by fitting placebo and hydrocortisone lymphocyte
data with equations (13) and (14). For the placebo data,
1220 • J Clin Pharmacol 2003;43:1216-1227
MAGER ET AL
Figure 2. Pharmacodynamic model for lymphocyte trafficking.
Glucocorticoids (Cp) inhibit the endogenous cortisol (Cen) secretion
rate (kin). Cp and Cen competitively inhibit movement of lymphocytes
(11)
from the extravascular (EV) to the blood (BL) pool.
(12)
only Cen is relevant according to equation (5). When hy-
drocortisone is dosed, Cp reflects Che based on equation
(10). Parameters estimated from modeling were kin, kbe,
and IC50, C. Parameters of lymphocyte dynamics for
prednisolone, methylprednisolone, and dexametha-
sone treatment were also estimated using equations
(13) and (14). Plasma concentrations of the dosed GC
and their resultant cortisol concentrations were fixed
(13)
functions derived from previous sections. The IC50, C
that was estimated from the placebo and hydrocorti-
sone data was also retained as a fixed value. The esti-
mated parameters were kin, kbe, and IC50, GC.
Neutrophil Dynamics
The elevation in blood neutrophils can be described
using indirect response model III21:

 dR  S max • C p 
, (14) = kin • 1 +  − kout • R, (15)
 dt  SC 50 + C p 

where R represents blood neutrophil counts, Smax is the
maximum stimulation factor, SC50 is the GC concentra-
tion producing 50% of Smax, kout is the first-order re-
moval rate of neutrophils, and the apparent zero-order
appearance of neutrophils is defined as kin = kout • R(0).
The Smax was fixed to 3.0 according to earlier observa-
tions.15,19
Since baseline neutrophils appear to be constant, it
was assumed that baseline cortisol concentrations
 DOSE EQUIVALENCY EVALUATION OF CORTICOSTEROIDS

have little or no effect on neutrophil profiles. The Cp for
hydrocortisone treatment is therefore the difference be-
tween the plasma concentration after treatment and
baseline cortisol concentrations (Chc in equation (9)).
By fixing the PK parameters derived for Cp, the
neutrophil cell counts from each treatment group were
fitted to estimate kout and SC50.
Dose Equivalency Determination
To determine the validity of currently accepted dose
equivalency tables, area under the effect-time curve
(AUEC) values were used as indicators of net
pharmacodynamic effects. The AUECs were generated
for each biomarker and were calculated as
Var(Y) = (σ1 + σ2 • Y)2, (17)
where the σi values are the variance model parameters,
and Y represents the model-predicted values. The
goodness of fit was assessed by convergence of the re-
gression analysis, the Akaike Information Criterion
and Schwarz Criterion (AIC and SC), the estimator cri-
terion value in ADAPT II, the correlation coefficients
(r 2), examination of residuals, and visual inspection.
The AUEC values of the biomarkers were compared
across drugs using repeated-measures ANOVA. If the
ANOVA was significant, then the Bonferroni correc-
tion test was performed. Statistical significance was
defined as p < 0.05. All statistical analyses were done
using SAS version 8.1 for Windows.

AUEC = |AUECplacebo – AUECtreatment|, (16) RESULTS

with areas obtained using the linear trapezoidal rule.
Due to their rebound patterns, the AUEC of T helper
and T suppressor cells only includes the 0- to 20-hour
time frames.
Data Analysis
All PK/PD model parameters were estimated by non-
linear regression analysis. The above models were fit-
ted to mean data (naive averaged data technique) using
WinNonlin (Pharsight Corp., Apex, NC), and data were
weighted by the inverse of the variance (1/y2). A stan-
dard two-stage analysis was also conducted in which
individual PK/PD profiles were fitted using the maxi-
mum likelihood estimator in ADAPT II (Biomedical
Simulations Resource, Los Angeles, CA). The variance
model in ADAPT was defined as
Pharmacokinetics
Figure 3 shows the mean plasma concentrations (± SD)
versus time, with the fitted curves generated from mod-
eling for each drug. Hydrocortisone, prednisolone, and
methylprednisolone PK profiles were best fitted with
monoexponential disposition functions. The disposi-
tion of dexamethasone was best described by a
biexponential equation. The estimated parameters re-
sulting from the PK analyses are listed in Table II. The
relatively low CV% values for the naive averaged data
were indicative of good model fitting. There was gener-
ally good agreement between parameter estimates ob-
tained by fitting mean or individual data. Note that the
CV% values for the standard two-stage method reflect
interindividual variability.

Table II Estimated Pharmacokinetic Parameters

a
Hydrocortisone Prednisolone Methylprednisolone Dexamethasone
NAD STS NAD STS NAD STS NAD STS
–1
k12 (h ) NA NA NA NA NA NA 1.11 (39) 1.73 (89)
k21 (h–1) NA NA NA NA NA NA 0.919 (13) 0.895 (26)
ka (h–1) NA NA 1.25 (21) 2.84 (110) NA NA NA NA
V/F (L)b 119 (15) 115 (14) 168 (9.9) 156 (20) 83.4 (8.1) 77.1 (14) 42.8 (22) 37.6 (44)
kel (h–1) 0.405 (9.4) 0.420 (18) 0.272 (4.8) 0.296 (13) 0.27 (4.2) 0.296 (13) 0.416 (20) 0.572 (45)
CL/F (L/h)b,c 48.2 48.6 (25) 45.7 45.3 (8.1) 22.5 22.7 (13) 17.8 18.2 (27)
Data reported as estimate and CV% (naive averaged data [NAD]) or mean and CV% of individual estimates (standard two-stage [STS]). NA, not applicable; k12,
k21, first-order rate constants of drug transport from central to peripheral compartment; ka, first-order absorption rate constant; V/F, volume of distribution cor-
rected for bioavailability; kel, first-order drug elimination rate constant; CL/F, total systemic clearance corrected for bioavailability.
a. Free drug.
b. F = 1 for intravenous hydrocortisone, methylprednisolone, and dexamethasone.
c. Calculated as kel • V/F.

PHARMACOKINETICS AND PHARMACODYNAMICS 1221

 MAGER ET AL

Placebo Prednisolone
Hydrocortisone Methylprednisolone
10000 160

1000 120

80
100
Plasma Glucocorticoid Concentration (ng/mL)

Cortisol Plasma Concentration (ng/mL)

40
10

0
1

Methylprednisolone Dexamethasone
Free Prednisolone Dexamethasone
1000 160

120
100

80

10 40

0
0 8 16 24 32 0 8 16 24 32
1
0 8 16 24 32 0 4 8 12 16 20 Time (hour)

Time (hour) Figure 4. Time course of mean (± SD) and fitted plasma cortisol
concentrations. The symbols represent experimental data, and the
Figure 3. Time course of mean (± SD) and fitted plasma glucocor- solid lines show the fittings of the model (equations (7) and (8)). The
ticoid concentrations. solid line for exogenous hydrocortisone is simulated based on Figure 1.

Pharmacodynamics kout, min value was calculated (0.32 h–1) and is the mini-
mum acceptable value of kout that ensures positive
values of Cen for the function represented by equation
Endogenous Cortisol
(7). The Fourier coefficients were substituted into
The mean cortisol concentrations (± SD) versus time equation (6) to characterize baseline cortisol secretion.
with the model fittings for each GC are shown in Fig- The estimated PD parameters of cortisol suppression
ure 4. The normal circadian variation in cortisol con- for each drug are shown in Table III. The estimated IC50
centrations is shown in Figure 4 as the baseline plot. of prednisolone of 1.25 ng/mL was comparable to that
The episodic nature of cortisol secretion is evident, of previous studies. 1 9 Although the methyl-
with the peak occurring at 8 a.m. and the nadir at about prednisolone IC50 was threefold lower than that of pre-
midnight. Figure 4 also shows the cortisol suppression vious studies,27 the variability for both studies was
after administration of GC. Cortisol concentrations rap- high, as suggested from individual fittings. Such infor-
idly decline and reach a nadir at approximately 5 mation is unavailable for hydrocortisone and
hours. After hydrocortisone and prednisolone doses, dexamethasone.
the circadian rhythm resumes around 15 hours later.
T Helper and T Suppressor Lymphocytes
After methylprednisolone, the circadian rhythm re-
sumes closer to 28 hours, whereas for dexamethasone, During baseline conditions, T helper and T suppressor
cortisol suppression continues past 32 hours. lymphocytes exhibit circadian rhythms reversed to
The Fourier coefficients obtained for the character- that of cortisol secretion, with the nadir occurring at 8
ization of mean baseline cortisol dynamics were a0 = a.m. and the peak at midnight, as shown in Figures 5
49.66, a1 = 28.23, b1 = 9.955, a2 = 10.39, and b2 = –8.606 and 6. After GC administration, a rapid decline of cell
(number of harmonics and calculated Fourier coeffi- counts occurs, with the nadir at about 5 hours. The T
cients for individual cortisol profiles is not shown). A helper cell counts returned to baseline levels at 12, 20,

1222 • J Clin Pharmacol 2003;43:1216-1227

 DOSE EQUIVALENCY EVALUATION OF CORTICOSTEROIDS

Table III Pharmacodynamic Parameters of Cortisol Suppression and Cell Trafficking

Placebo and
Hydrocortisone Prednisolonea Methylprednisolone Dexamethasone
Treatment NAD STS NAD STS NAD STS NAD STS

Cortisol suppression
IC50 (ng/mL) 8.01 (70) 4.61 (114) 1.25 (14) 1.87 (34) 0.52 (37) 1.87 (89) 0.172 (30) 0.105 (62)
kout (h–1) 0.405 (9.4) 0.420 (18) 1.54 (26) 1.73 (62) 0.405b —c 0.405b —c
T helper cell
trafficking
IC50, C (ng/mL) 52.4 (30) 56.4 (31) 52.4b —c 52.4b —c 52.4b —c
IC50, GC (ng/mL) NA NA 5.76 (14) 5.35 (41) 9.93 (12) 11.1 (138) 3.36 (14) 4.00 (118)
kin (cell/µL/h) 695 (16) 724 (23) 947(8.5) 1120 (16) 862 (7.2) 1090 (33) 960 (9.2) 989 (51)
kbe (h–1) 0.324 (16) 0.329 (30) 0.349 (7.4) 0.361 (24) 0.350 (6.1) 0.415 (35) 0.441 (7.8) 0.415 (34)
T suppressor
cell trafficking
IC50, C (ng/mL) 99.5 (40) 103 (17) 99.5b —c 99.5b —c 99.5b —c
IC50, GC (ng/mL) NA NA 21.1 (10) 19.2 (11) 58.0 (11) 41.7 (37) 18.7 (18) 18.0 (26)
kin (cell/µL/h) 197 (19) 328 (34) 328 (8.1) 375 (20) 338 (9.7) 494 (113) 568 (20) 596 (102)
kbe (h–1) 0.197 (24) 0.327 (39) 0.282 (8.4) 0.281 (32) 0.308 (10) 0.389 (82) 0.492 (21) 0.427 (54)
Neutrophil trafficking
SC50 (ng/mL) 155 (25) 179 (37) 20.5 (21) 41.0 (102) 26.4 (32) 36.0 (90) 7.93 (27) 6.07 (88)
kout (h–1) 0.0732 (13) 0.0562 (22) 0.0451 (11) 0.0657 (13) 0.0621 (16) 0.0883 (49) 0.0646 (17) 0.0715 (35)
Data reported as estimate and CV% (naive averaged data [NAD]) or mean and CV% of individual estimates (standard two-stage [STS]). IC50, drug concentration
producing 50% of cortisol secretion; IC50, C, cortisol concentration producing 50% inhibition of T cell trafficking into circulation; IC50, GC, drug concentration
producing 50% inhibition of T cell trafficking into circulation; kbe, first-order rate constant of removal of T cells from circulation; kin, apparent zero-order rate
constant of appearance of T cells in circulation; kout, first-order rate constant of cortisol elimination or systemic removal of neutrophils; NA, not applicable; SC50,
drug concentration producing 50% maximum stimulation of neutrophil cell production.
a. Free drug.
b. Fixed values.
c. Fixed to individual values estimated for placebo and hydrocortisone.

18, and 24 hours after dosing with hydrocortisone,
prednisolone, methylprednisolone, and dexametha-
sone, respectively. The T suppressor cell counts re-
turned to baseline at 16 hours after dosing. A rebound
phenomenon is observed that continues past the 32-
hour time point. The PD parameters obtained from
modeling are presented in Table III. Parameters esti-
mated for the prednisolone treatment were comparable
to those of previous studies.19 The IC50, GC value of
methylprednisolone was found to be only half of the
previous study but again may reflect interindividual
variability.27 Such PD parameters of the other GC for
cell trafficking were not found.
Neutrophils
Figure 7 shows the mean plasma neutrophil cell counts
(± SD) versus time with the fitted curves. Baseline
neutrophil levels were constant at approximately 3.58 ×
106 cells/mL (data not shown). The estimated PD pa-
rameters also are listed in Table III. The IC50 estimated
for prednisolone was similar to that found by Magee
et al.19 Similar data were unavailable for the other GC.
Dose Equivalency Determination
Comparisons of relative responses were made by exam-
ining calculated AUEC values. The mean AUEC (± SD)
values of the evaluated biomarkers are listed in Table IV.
For T helper cells, there was a significant difference be-
tween the groups (p = 0.014), with dexamethasone
showing almost a twofold higher activity than hydro-
cortisone. Subsequent post hoc analysis using the
Bonferroni method showed no difference. For cortisol
suppression, prednisolone and dexamethasone
showed a greater effect than hydrocortisone and
methylprednisolone. Similar to the T helper cell com-
parison, there was a significant difference between
groups (p = 0.022) with the initial analysis, while sub-
sequent post hoc analysis using the Bonferroni method
showed no differences.
DISCUSSION
We have reevaluated the validity of the dose equiva-
lency table of GC by following cell trafficking dynam-

PHARMACOKINETICS AND PHARMACODYNAMICS 1223

 MAGER ET AL

Placebo and Hydrocortisone Prednisolone Hydrocortisone Prednisolone

2500 10

2000 8

1500 6

1000 4

Neutrophil Cell Count (x106 cells/mL)

T-helper Cell Count (x103 cells/mL)

500 2

0 0

Methylprednisolone Dexamethasone Methylprednisolone Dexamethasone

2500 10

2000
8

1500
6

1000
4

500
2

0
0 8 16 24 32 0 8 16 24 32 0
0 8 16 24 32 0 8 16 24 32
Time (hour)
Time (hour)

Figure 5. Time course of mean (± SD) and fitted T helper lympho- Figure 7. Time course of mean (± SD) and fitted neutrophil cell
cyte cell counts. The placebo baseline phase is represented by the counts. Symbols and lines are as in Figure 5.
open circles. The treatment data (䊉) and model-fitted profiles (solid
and broken lines) are shown.

ics and adrenal suppression effects using moderate

Placebo and Hydrocortisone Prednisolone
doses of the drugs. Although studies have shown no
1600
differences in the qualitative anti-inflammatory prop-
erties with equivalent doses, these were reported in the
1200 late 1960s and early 1970s.28,29 With the increase in use
of GC, the integrity of the dose equivalency table has
800
become an important clinical consideration. The ad-
T-supressor Cell Count (x 103 cells/mL)

400
vent of sophisticated assays and mechanistic modeling
approaches can provide for a scientifically based
0 evaluation of the dose equivalency table.
The PK parameter values estimated for this study
were comparable to those of previous investiga-
Methylprednisolone Dexamethasone tions.19,30 The free prednisolone concentrations were
2000 used in this study due to nonlinear protein-binding
1600
characteristics.30 The estimated PK parameters were
fixed and used in indirect response models that were
1200 applied to estimate PD parameters. The results of fit-
800
ting mean and individual PK/PD data are reported, and
final estimates were similar between methods (Tables
400 II and III).
0
The cortisol dynamic model presented in this study
0 8 16 24 32 0 8 16 24 32 is an extension of the indirect response model I,21 in
Time (hour)
which the baseline input followed a circadian-episodic
profile. The input function for the mean cortisol base-
Figure 6. Time course of mean (± SD) and fitted T suppressor lym-
phocyte cell counts. Symbols and lines are as in Figure 5. line was modeled using a two-harmonic Fourier analy-

1224 • J Clin Pharmacol 2003;43:1216-1227

 DOSE EQUIVALENCY EVALUATION OF CORTICOSTEROIDS

Table IV AUEC Values of Measured Pharmacodynamic Markers

Marker Hydrocortisone Prednisolone Methylprednisolone Dexamethasone p-Value

T helper cells (103 cells•h/mL)a

Mean 9730 13,100 12,500 16,800 0.014
Standard deviation 4630 8700 7910 8000
T suppressor cells (103 cells•h/mL)a,b
Mean 4870 6070 5490 6900 0.43
Standard deviation 2270 6050 4120 3660
Neutrophils (103 cells•h/mL)
Mean 42.7 65.3 111 129 0.14
Standard deviation 26.8 30.1 57.9 40.6
Cortisol (ng•h/mL)
Mean 1070 1510 1150 1430 0.022
Standard deviation 230 452 394 237
a. Area under the effect-time curve (AUEC) value calculated from 0 to 20 hours only.
b. AUEC value of 1 subject was excluded due to abnormally low T suppressor cells during the placebo period.

sis, as presented by Chakraborty et al.31 This technique

provided a very good fitting to the data, as shown in the
cortisol baseline graph of Figure 4. The inhibition func- 2

tion of equation (8) then accounts for the suppression

of cortisol secretion by the administered drugs. Due to
the inability of our assay to distinguish between endog- 1

enous and administered hydrocortisone, the measured

log ( 1 / EC50 )

cortisol concentrations reflect both values. The PK pa-

rameters and cortisol PD parameters of hydrocortisone
treatment were therefore estimated simultaneously by
linking the two models together, as shown in Figure 1.
For all other treatments, the PK parameters were first
determined and then fixed in the cortisol dynamic
model.
The lymphocyte PD model used in this study was
modified from previous studies,32,33 in which the lym-
phocyte cell trafficking compartments were simplified
to the extravascular and blood pools. This model
jointly accounts for the direct effect of GC and the GC-
suppressed cortisol effect on lymphocyte trafficking.
The neutrophil PD model used in this study was the
simple indirect response model III.21 The baseline
neutrophil counts, under the influence of baseline
cortisol concentrations, were considered to be con-
stant. Therefore, the drug concentrations, Cp, that drive
the response during hydrocortisone treatment were the
difference between total cortisol measured and the
baseline concentrations. For all other treatments,
cortisol concentrations were less than baseline and
thus have little or no contribution to neutrophil
dynamics.
The major initiating event in corticosteroid pharma-
codynamics is receptor binding. The EC50 values re-
ported in Table III (IC50 and SC50 parameters) were in
0
-1
-2
1 2
log RRA
Figure 8. Correlation between log-reciprocal EC50 values (IC50 and
SC50 values by naive averaged data [NAD] in Table III) and relative
30
receptor affinity (RRA) from Jusko and Ludwig (hydrocortisone, 9;
prednisolone, 16; methylprednisolone, 42; dexamethasone, 100).
Symbols and regression lines are shown for cortisol suppression (䊉,
2
r 2 = 0.95, p < 0.05), T helper cells (䉮, r = 0.999, p < 0.001), and T sup-
2
pressor cells and neutrophils (䊏, 䉫, r = 0.829, p < 0.005).
fact well correlated with reported relative receptor af-
finity values (equilibrium dissociation constants
normalized to dexamethasone),30 as shown in Figure 8.
To compare values with prednisolone, which was
based on free drug concentrations, we corrected the
EC50 values for hydrocortisone, methylprednisolone,
and dexamethasone for protein binding (respective
free fractions = 0.20, 0.23, and 0.32).34 Whereas the EC50

PHARMACOKINETICS AND PHARMACODYNAMICS 1225

 MAGER ET AL
values for each GC were biomarker dependent, the
good correlation to receptor affinity was found across
all GC for each tested biomarker and is in agreement
with previous reports of this relationship.34
Although significant differences were found with T
helper cells and cortisol suppression effects in the
comparison of AUEC to assess dose equivalency,
post hoc Bonferroni analysis showed no difference be-
tween treatments. Post hoc analysis using the Fisher’s
least significant difference test (LSD) resulted in a dif-
ference between hydrocortisone and dexamethasone
effects on T helper cells. For the cortisol suppression
comparison, LSD also found hydrocortisone to differ
from dexamethasone and prednisolone, while
methylprednisolone differs from prednisolone. The
Bonferroni method is stricter than LSD and is the better
of the two methods for this type of comparison. Al-
though limited by the study of single doses and a small
sample size, these results suggest that there are no sig-
nificant differences between the treatments based on
AUEC analysis. In consideration of the small sample
size, the number of subjects may have been inadequate,
and thus there is a possibility that true differences exist
among the drugs, which may or may not be clinically
relevant. Study of a larger population size using more
than one GC dosage level may be needed to ascertain
possible modest differences between these drugs. The
dosage levels are important as AUEC values change
nonlinearly with dose, although they are proportional
to log dose at higher dosage levels, making compari-
sons such as these somewhat complicated.35
We thank the clinical staff of the Buffalo Clinical Research Labora-
tory and Ms. Nancy Pyszczynski and Ms. Suzette Mis for providing
valuable technical support. Special thanks also go to Mr. David Collins
for his assistance with the statistical analyses.
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