Prednisone: Benefits and Risks

Side effects increase in tandem with the duration of use

Older patient with doctor
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Prednisone is a potent corticosteroid drug used to treat inflammatory forms of arthritis as well as some types of cancer and autoimmune disease. It is available in tablet and liquid formulations and functions as an immunosuppressant, tempering inflammation by blunting the immune response.

How Prednisone Works

Inflammation is the body's natural response to anything it considers harmful.

When the immune system identifies a harmful agent, it releases chemicals into the bloodstream which cause tissues to swell, in part to increase the size of blood vessels and allow larger immune cells closer access to the site of an injury or infection.

With certain autoimmune disorders, the immune response is abnormal and excessive. Such is the case with rheumatoid arthritis (RA) wherein the immune system will mistakenly attack healthy joints. Acute RA symptoms can often flare without notice, causing increased pain, swelling, and injury to the affected joint.

Prednisone has the ability to control these flares by quickly alleviating the inflammation until other disease-modifying anti-rheumatic drugs (DMARDs) can take effect. While DMARDs like Plaquenil (hydroxychloroquine) and Arava (leflunomide) are more targeted in the control of the immune system, they are slower acting.

By contrast, prednisone is fast in providing relief but has a number of side effects that limit its use, particularly over the longer term.

Unlike DMARDs, prednisone does not target a specific cell or biological function. Instead, it works systemically, flooding the body and affecting many different types of cells and functions. It is for this reason that prednisone can provide relief on the one hand and cause problems on the other.

Side Effects

The side effects of prednisone can range from mild to severe.

They occur more frequently at higher dosages or with long-term use.

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

The 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, glaucoma, or cataracts
  • Muscle weakness and atrophy
  • Thinning or 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

Prescribing Information

Prednisone is available in both an immediate-release and delayed-release formulation. For the treatment of RA in adults, the drug is prescribed as follows:

  • Immediate-release prednisone is prescribed in a daily dose of less than 10 milligrams per day taken with a DMARD.
  • Delayed-release prednisone is prescribed in a daily dose of five milligrams to start, followed by the lowest possible maintenance dose to maintain a good clinical result.

    Prednisone is usually taken as a single dose during breakfast to better prevent stomach upset.

    For persons 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.

    Drug Interactions

    Prednisone is known to have numerous drug-drug interactions. In some cases, the secondary drug may increase the bioavailability 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 such as clarithromycin or rifampin
    • Antidepressants such as Zoloft (sertraline) and Prozac (fluoxetine)
    • Anti-seizure drugs like carbamazepine and phenytoin
    • Antifungal drugs such as Diflucan (fluconazole) and Sporanox (itraconazole)
    • Anti-nausea drugs such as Emend (aprepitant)
    • Asthma medications like Accolate (zafirlukast)
    • Aspirin
    • Blood thinners such as Coumadin (warfarin)
    • Diuretics ("water pills")
    • Heart medications such as verapamil, diltiazem, and amiodarone
    • Heartburn medications such as Tagamet (cimetidine)
    • HIV medication such as Reyataz (atazanavir), Crixivan (indinavir), and Kaletra (lopinavir/ritonavir)
    • 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.

    Always be sure to advise your doctor of any and all drugs or supplements you may be taking, whether they are prescription, non-prescription, herbal, nutritional, or traditional.

    Other Considerations

    During pregnancy, prednisone should only be used when clearly needed. It has not been shown to cause harm to the fetus in animal studies. The drug can be passed to a newborn through breast milk but is not known to cause any harm. Always weight the benefits and risk with your doctor before starting treatment.

    Be advised that the liquid formulation contains both sugar and alcohol. You may need to use the tablet formulation if either of these substances adversely affects a medical condition such as diabetes or liver disease.

    Finally, if you have been taking prednisone for a while, you should not discontinue treatment suddenly. Tapering the drug slowly will help you avoid or minimize the side effects caused by the sudden termination of treatment.

    View Article Sources
    • Firestein, G.; Budd, R.; Gabriel, S. et al. (2017) Kelley and Firestein's Textbook of Rheumatology (10th ed.). Philadelphia, Pennsylvania: Elsevier: ISBN: 9780323316965.