Corticosteroid
Methylprednisolone (Solu-Medrol)
Also called Solu-Medrol
Indications
- Asthma and COPD exacerbations when oral prednisone cannot be taken
- Anaphylaxis and angioedema, as an adjunct to epinephrine (weak evidence)
- Early moderate to severe ARDS (off-label)
- Post-extubation stridor prevention after a failed cuff-leak test, at least 4 h before extubation (off-label)
- Pulse therapy (up to 1 g a day for 3–5 days) for multiple sclerosis relapse or lupus flares
- Transplant rejection, vasculitis and severe checkpoint-inhibitor toxicity (off-label)
Dosing
| Where | Dose |
|---|---|
| Other common pushes | Methylprednisolone: 125 mg IV (asthma, anaphylaxis adjunct); 1 g for spinal cord injury is no longer recommended |
| Corticosteroid equivalence | Methylprednisolone: 4 mg (little mineralocorticoid effect) |
On the quick cards
- Methylprednisolone (Solu-Medrol)EMS Field Drugs: Respiratory and allergy: IV corticosteroid
- Other common pushesPush and Emergency Meds: Analgesia, antiemetics, steroids, diuretics, TXA
- Corticosteroid equivalenceEquivalents and Conversions: Glucocorticoid doses with the same anti-inflammatory effect
Mechanism of action
Methylprednisolone binds the cytoplasmic glucocorticoid receptor, which moves to the nucleus and switches anti-inflammatory and metabolic genes on, or tethers NF-κB and AP-1 to switch cytokines, adhesion molecules, COX-2 and inducible NO synthase off; these genomic effects take hours. Receptors are nearly saturated above about 100 mg of prednisone-equivalent a day (80 mg of methylprednisolone), so the extra effect of pulse doses is credited to non-genomic actions: membrane-bound receptors, signaling proteins released from the receptor complex and direct membrane effects that damp immune cells within minutes.
Pharmacology
- Respiratory: reduces airway inflammation, edema and mucus and restores β2-receptor responsiveness; benefit takes hours, so give it early
- Immune: lymphocytes and eosinophils fall within hours; high doses suppress T-cell and antibody responses
- Renal: per mg it has 5 times the glucocorticoid and half the mineralocorticoid potency of hydrocortisone, so an equivalent dose (4 mg for 20 mg) carries a tenth of the salt retention
- Metabolic: hyperglycemia, often marked after pulses; protein catabolism
Pharmacokinetics
| Onset | IV: effects within 1 h (label); anti-inflammatory benefit builds over hours |
|---|---|
| Duration | Biologic effect 12–36 h |
| Half-life | Plasma 2.4–3.5 h (SmPC range 1.8–5.2 h); the succinate ester is hydrolyzed in about 4 min |
| Distribution | Vd about 1.4 L/kg; crosses the blood-brain barrier and into breast milk |
| Protein binding | About 77%, mainly albumin; linear, since it binds little to CBG |
| Metabolism | Liver CYP3A4 to inactive 20α- and 20β-hydroxy metabolites; P-glycoprotein substrate |
| Elimination | Urine as metabolites; nearly complete within 12 h (label) |
Chemistry
- 6α-methylprednisolone: the 1,2 double bond adds glucocorticoid potency and slows metabolism, and the 6α-methyl group lowers salt retention below prednisolone's
- A neutral, lipophilic steroid nearly insoluble in water; the IV form is the 21-sodium succinate ester, buffered to pH 7–8
- Solu-Medrol 40 mg (with cow's milk lactose) and 125 mg vials are preservative-free; some larger vials contain benzyl alcohol. Use within 48 h of mixing, 4 h once diluted (24 h refrigerated)
- Depo-Medrol (the acetate) is a depot suspension for IM or joint injection only, never IV
Adverse effects and cautions
In the one-pagers
- Ventilator Liberation and TracheostomyBefore the tube comes out: Methylprednisolone 40 mg once 4 h before (Cheng 2011) or 20 mg every 4 h from 12 h before (François 2007); dexamethasone 5 mg every 6 h × 4 (Lee 2007).
- Asthma and COPD ExacerbationsBronchodilators, steroids, magnesium and parenteral β-agonists: Methylprednisolone IV: 40–80 mg/day if unable to swallow: Higher doses add nothing
- Spinal Motion RestrictionSteroids, early surgery and what is unsettled: NASCIS II (Bracken 1990) gave methylprednisolone 30 mg/kg over 15 minutes, then 5.4 mg/kg/h for 23 hours; the primary analysis was negative, and only a post hoc subgroup treated within 8 hours gained about 5 motor points. NASCIS III (1997) found more severe pneumonia with 48 than 24 hours of treatment. AANS/CNS 2013 recommends against methylprednisolo
- ACLS Algorithms in BriefDrugs in arrest: what the trials show: Vasopressin with methylprednisolone: VAM-IHCA 2021: ROSC 42% vs 33%, 30-day survival 9.7% vs 12%: Not routine
- Airway and RSIExtubation readiness and post-extubation stridor: Post-extubation stridor comes from laryngeal edema; risk rises with traumatic or repeated intubation, intubation over about 6 days, a large tube and female sex. For the cuff leak test, deflate the cuff on volume control and compare inspired with expired volume; a leak under 110 mL (Miller and Cole 1996) or under about 10–25% of tidal volume predict
- ARDSFluids, steroids and the pharmacologic trials: Corticosteroids blunt the inflammatory and fibroproliferative response. DEXA-ARDS (Villar 2020; 277 patients, P/F ≤200 on PEEP ≥10 and FiO₂ ≥0.5 at 24 h) gave dexamethasone 20 mg daily for 5 days then 10 mg for 5 days: 4.8 more ventilator-free days and 60-day mortality 21% vs 36%, hyperglycemia 76% vs 70%, no excess infection. In COVID-19, RECOVERY (2
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Other corticosteroid drugs
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Sources
- FDA label: Solu-Medrol (2025)
- UK SmPC: Solu-Medrone (2026)
- Buttgereit 2002 (non-genomic effects)
- AANS/CNS spinal cord injury guideline (2013)
For education and exam preparation only. Follow your institution’s protocols. Typical adult values for study. Follow your local protocols and medical direction.