What to Know About Prednisone for Rheumatoid Arthritis

There are several benefits, interactions, and warnings to consider when taking prednisone. Prednisone is a potent, short-acting oral corticosteroid commonly prescribed on a short-term basis in low doses to manage pain and inflammation in the treatment of rheumatoid arthritis (RA) and other inflammatory diseases.

Uses

Inflammation is the immune system's response to anything it considers harmful, such as an injury or infection. In RA, the immune system mistakenly attacks healthy joints, usually causing pain and swelling.

Prednisone reduces inflammation by stimulating the glucocorticoid receptors in the cells, which causes suppression of cytokines (proteins that serve as "messengers" between cells).

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.

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 a duration.

Other Uses

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

• Severe allergic reactions
• Asthma
• Acute flares of multiple sclerosis
• Lupus
• Ulcerative colitis
• Certain cancers

Before Taking

Prednisone is commonly prescribed for treating joint pain and inflammation even before an official diagnosis is made.

Reaching an RA diagnosis can be complicated and take some time, as other conditions must be ruled out. Prednisone can help temper symptoms while this process plays out. As the drug can be helpful for a variety of inflammatory diseases, it may be helpful even if you aren't eventually found to have RA.

Corticosteroids like prednisone and its chemical cousin prednisolone are often used 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 that 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 in your specific situation. Certain health conditions increase the risk of side effects when taking prednisone. Be sure to tell your doctor if you have any of the following: 

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

Women who are pregnant or may become pregnant should discuss the potential risks prednisone may pose to an unborn child. Taking prednisone during pregnancy has been linked to cleft palate, preterm birth, and low birth weight in infants, as well as 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 immediate-release and delayed-release formulations, which are taken by mouth.

The usual dose of prednisone is 5 milligrams (mg) to 10 mg daily. People with RA who are experiencing extra-articular symptoms, such as eye or lung inflammation, are more likely to be receiving higher prednisone doses, which can be as high as 60 mg/day.

For the treatment of RA in adults, the drug is prescribed as follows:

• Immediate-release prednisone is prescribed in a daily dose lower than 10 mg per day taken with a DMARD.
• Delayed-release prednisone is prescribed at a dose starting at 5 mg per day, followed by the lowest possible maintenance dose to maintain a good clinical result.

Prednisone is usually taken in the morning (this is your most alert time based on your circadian rhythm) and with food (to help prevent stomach upset).

For people with severe RA, 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. And you might receive a prescription for daily treatment or intermittent treatment.

Prednisone is also approved for use in children; a pediatrician or rheumatologist can determine the proper dose based on a child's condition and age.

Side Effects

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

Common

Short-term side effects are similar to those of other corticosteroid drugs and may include:

• Fluid retention
• Gastrointestinal upset (stomach pain, diarrhea)
• Elevated blood glucose

Severe

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

These effects may include:

• High blood pressure
• Persistent fatigue
• Mood changes, including sudden bouts of anger
• Diminished concentration or confusion
• Depression and anxiety
• Insomnia
• Weight gain
• Facial puffiness and swelling
• Irregular menstruation
• Peptic ulcers
• 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 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 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 medications like Crixivan (indinavir), Kaletra (lopinavir/ritonavir), and Reyataz (atazanavir)
• Hormonal contraceptives
• Immunosuppressant drugs
• Other corticosteroids
• St. John's wort

Combining NSAIDS with prednisone can increase the risk of peptic ulcers, which may cause bleeding and lead to hospitalization.

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, but that production is decreased if you have been on prednisone for a period of time.

Tapering the drug slowly will help you avoid or minimize the adverse 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.