What to Know About Prednisone for Rheumatoid Arthritis

Prednisone is a potent corticosteroid drug commonly used in the treatment of rheumatoid arthritis (RA) and other inflammatory diseases. A generic drug developed in the 1950s, prednisone is typically prescribed on a short-term basis in low doses to relieve pain and inflammation associated with an arthritis flare-up.

Uses

Prednisone is used to treat inflammation associated with rheumatoid arthritis. Inflammation is the immune system's response to anything it considers harmful, such as an injury or infection. In rheumatoid arthritis (RA) the immune system mistakenly attacks healthy joints, causing increased pain and swelling.

Prednisone stimulates the glucocorticoid receptors in the cells, which causes suppression of cytokines, helping to reduce inflammation, along with the pain and stiffness associated with it. A short-acting medication, prednisone is effective in quickly by relieving inflammation, but it is not recommended for longterm use.

The recommended first-line treatment for RA is disease-modifying anti-rheumatic drugs (DMARDs), however, these drugs can take eight to 12 weeks to start working. Prednisone is often used as a "bridge therapy" to provide relief before DMARDs take effect.

The downside of prednisone: Unlike DMARDs, it doesn't target a specific cell or biological function. Instead, it works systemically, flooding the body and affecting many different types of cells and functions. So while prednisone provides fast relief, it has a number of side effects that limit its use, particularly over the longer term.

Other Uses

In addition to treating RA and other types of arthritis, prednisone is commonly prescribed in the treatment of:

• Severe allergic reactions
• Asthma
• Multiple sclerosis
• Lupus
• Ulcerative colitis
• Certain cancers

Before Taking

Prednisone is commonly prescribed for joint pain and inflammation that presents similarly to RA even before an official diagnosis is given.

A short-acting drug, prednisone typically starts working in about an hour and stays in your system for about a day. Repeated doses should bring noticeable relief to an arthritis flare in 24 to 48 hours.

Corticosteroids like prednisone and its chemical cousin prednisolone are often given on a trial basis prior to diagnosis to differentiate between RA and osteoarthritis (OA). A 2017 study published in the journal Arthritis Research and Therapy reported a 40% reduction in pain on day three of a prednisolone trial (pred-test) was a key indicator of RA over OA.

Precautions and Contraindications

Before prescribing prednisone, your doctor will weigh the risks versus the benefits for your personal health needs. Certain health conditions pose more of a risk when taking prednisone. Be sure to tell your doctor if you have any of the following: 

• Anxiety or other emotional conditions
• Diabetes
• Eye infection or a history of eye infections
• Heart disease
• High blood pressure
• Intestinal disease
• Kidney disease
• Liver disease
• Mental health conditions
• Myasthenia gravis
• Osteoporosis
• Seizures
• Threadworms (a type of worm that can live inside the body)
• Thyroid disease
• Tuberculosis (TB)
• Ulcers

Women who are pregnant or may become pregnant should discuss the potential risks of prednisone may pose to the unborn child. Taking prednisone during pregnancy has been linked to oral clefts, preterm birth, and low birth weight in infants and preeclampsia and gestational diabetes in mothers.

Prednisone is contraindicated in people who are allergic to prednisone or an inactive ingredient in the medication. Tell your doctor if you have had any unusual or allergic reactions to this or any medicine. 

Dosage

Prednisone is available in both an immediate-release and delayed-release formulation. The usual dose of prednisone is 5 milligrams (mg) to 10 mg daily. RA patients who are experiencing extra-articular symptoms such as eye or lung inflammation are more likely to be on larger doses of prednisone, which can be as high as 60 mg/day.

Prednisone is usually taken in the morning to coincide with your circadian rhythm and is taken during breakfast to better prevent stomach upset.

For people with severe rheumatoid arthritis, the delayed-release formulation may be taken at bedtime to decrease morning stiffness and pain.

The duration of treatment must be made on an individual basis, weighing the benefits and risks, and deciding whether daily or intermittent treatment is most appropriate.

Side Effects

The side effects of prednisone can range from mild to severe, depending on the strength of the dose and for how long you take it. They occur more frequently at higher dosages or with long-term use.

Common

Short-term side effects are similar to that of other corticosteroid drugs and may include fluid retention, gastrointestinal upset (stomach pain, diarrhea), and an increase in blood glucose.

Being on prednisone can significantly weaken your bones, resulting in osteoporosis, and can increase your risk of infections. This is the reason rheumatologists will always try to keep patients on the lowest dose possible.

Severe

More serious problems arise, however, when treatment continues for longer periods of time, increasing in intensity as the duration or dosage increases. Side effects may include:

• High blood pressure
• Persistent fatigue
• Mood changes, including sudden anger
• Loss of concentration or confusion
• Depression and anxiety
• Insomnia
• Weight gain
• Severe facial swelling
• Irregular menstruation
• Peptic ulcer
• Blurred vision, cataracts, or glaucoma
• Muscle weakness and atrophy
• Thinning of skin
• Easy bruising
• Increased risk of infection due to immune suppression
• Osteoporosis and the increased risk of fractures
• Bone death (osteonecrosis)
• Fatty liver disease (hepatic steatosis)
• Psychosis
• Stunted growth in children

Warnings and Interactions

Prednisone is known to have numerous drug-drug interactions. In some cases, the secondary drug may increase the bioavailability, or absorption, of prednisone and, with it, the severity of side effects. In other cases, prednisone may interfere with the activity of the secondary drug.

Known drug-drug interactions include:

• Antibiotics like clarithromycin or rifampin
• Antidepressants like Prozac (fluoxetine) and Zoloft (sertraline) 
• Anti-seizure drugs like carbamazepine and phenytoin
• Antifungal drugs like Diflucan (fluconazole) and Sporanox (itraconazole)
• Anti-nausea drugs like Emend (aprepitant)
• Asthma medications like Accolate (zafirlukast)
• Aspirin
• Blood thinners like Coumadin (warfarin)
• Diuretics ("water pills")
• Heart medications like amiodarone, diltiazem, and verapamil
• Heartburn medications like Tagamet (cimetidine)
• HIV medication like Crixivan (indinavir), Kaletra (lopinavir/ritonavir), and Reyataz (atazanavir)
• Hormonal contraceptives
• Immunosuppressant drugs
• Other corticosteroids
• St. John's wort

Additionally, high-dosage or prolonged use of prednisone may reduce the immune response to certain vaccines and make them less effective. If you have been heavily treated with prednisone, you should wait for at least three months after stopping before getting a live vaccine.

Discontinuing Use

If you have been taking prednisone for a while, you should not discontinue treatment suddenly. The adrenal glands typically make a natural amount of cortisol (steroid hormone) every day and if you have been on prednisone for a period of time, the adrenal glands have decreased cortisol production.

Tapering the drug slowly will help you avoid or minimize the side effects caused by the sudden termination of treatment. Withdrawal symptoms may include severe fatigue, weakness, body aches, and joint pain. Tapering prednisone is an attempt to 'wake up' your adrenal glands, so they can start doing their job again.