Adrenal suppression and Cushing’s syndrome like symptoms are the feared prednisone side effects with long term use, whereas weight gain, fluid retention, and psychologic side effects are the major concerns with short term use. All of these and much more will be addressed in this post in detail.

Trade Names: Although available in several branded formulations, prednisone is almost universally referred to by its generic name.  Prednisone is available in numerous oral doses including 1 mg, 2.5 mg, 5 mg, 10 mg, 20 mg and 50 mg tablets and a 5mg/5ml liquid.   Prednisone is a commonly used corticosteroid medication that is used primarily because of its potent anti-inflammatory effect via suppression of the immune system.  Corticosteroids get their name because of the naturally produced steroid structured hormone in this class C called cortisol, which is produced in the adrenal cortex.  Another name for this class of medications is glucocorticoids.  One of the major prednisone side effects, elevation of blood glucose levels, is common to this class of medications leading to the name glucocorticoids.  Typical medical problems treated with prednisone include asthma, severe allergic reactions, and autoimmune disorders like rheumatoid arthritis, systemic lupus erythematosis, and polymyalgia rheumatica.

Common Prednisone Side Effects with short term use: Prednisone causes at least some side effects in many patients.  Often patients notice fluid retention particularly in the ankles, but sometimes all over.  Appetite tends to be increased as a prednisone side effect, and weight gain is common even with short term use.  Anxiety, agitation, and nervousness are also common prednisone side effects.  Insomnia can be a common result of these psychological prednisone side effects. Elevation of blood sugar is common, often leading to a diagnosis of diabetes in patients not previously known to have diabetes. Suppression of the immune system is a nearly universal prednisone side effect, and is related directly to its mechanism of use.  This is usually not of clinical significance, but it can lead to delayed wound healing in postoperative patients.  Acid dyspepsia gastritis, and peptic ulcers are occasionally seen as prednisone side effects.

Longer Term Use Prednisone Side Effects:  Prednisone has common but usually minor side effects when used for very short courses of therapy.  When used for less than 2 weeks it is very unlikely that the body’s ability to produce its own cortisol will be suppressed. A nearly universal prednisone side effect is adrenal insufficiency when it is used for longer periods, especially several weeks or longer as is often needed for chronic autoimmune conditions.  This occurs when the adrenal gland’s ability to produce cortisol in response to stress or the body’s needs is suppressed by long term corticosteroid therapy. This can be a life threatening condition, especially if major stress or trauma like pneumonia or other serious infection or major surgery or physical trauma occurs. With long term prednisone use it is necessary to use a prednisone taper in order to allow the adrenal system to regain its capacity to respond to demand for cortisol production. With long term low dose prednisone use if a patient needs surgery, has major trauma, or encounters any type of major physiologic stress they often require coverage with additional corticosteroid therapy at higher dosage during that time to prevent adrenal insufficiency crisis.

Serious Prednisone Side Effects: With long term use a condition called Cushing’s syndrome occurs, leading to many classic and serious prednisone side effects.  These include weight gain, bone density loss, a moon shaped face, a fat deposition on the upper back called a buffalo hump, thinned skin that bruises easily, stretch marks on the torso and legs, and in women especially facial and body hair growth.  Other serious prednisone side effects include immunosuppression and serious opportunistic infections, steroid psychosis, very high blood sugars and onset of diabetes mellitus, pseudotumor cerebri, gastrointestinal peptic ulcers, seizures, glaucoma, steroid myopathy, high blood pressure, congestive heart failure, ruptured tendons, among others.  See the manufacturers prescribing guidelines for complete details.

Drug Interactions: Prednisone is contraindicated for use with any live vaccines including live intranasal influenza vaccine, MMR, smallpox vaccine, and live BCG vaccine.  The concern is that the attenuated live virus may lead to illness due to the immunosuppression from prednisone.  Mifepristone and adesleukin are strong contraindications to the use of prednisone.

Pharmacology:  Prednisone is primarily metabolized by the liver and the CYP450 pathway.  Prednisone is a prodrug, and is metabolized into prednisolone, as a 3A4 substrate.  The prednisone biologic half life is approximately 18-36 hours.

Pregnancy and Lactation Class: Prednisone is category C in pregnancy, and considered probably safe during lactation.

Special Considerations: Latent infections like tuberculosis can potentially be allowed to reactivate by the immunosuppression of prednisone.  A history of a positive PPD (TB skin test) is a reason to avoid prednisone use.  A history of psychosis, especially steroid psychosis is a strong contraindication to prednisone use.  Diabetic patients require special monitoring with prednisone use, because of the hyperglycemia prednisone side effect.

The completely different prednisone side effects between short term use and long term use cannot be emphasized enough.  The issues with long term use are almost universally noted, whereas the prednisone side effects with short term use are infrequent and transient.  Most patients can safely use a burst course of prednisone for conditions like asthma, acute joint inflammation, acute gout or a flare-up in many other diseases, but physicians make every effort to avoid long term prednisone use if at all possible.  The prolonged taper needed to stop long term prednisone use is difficult, and the alternative of continuing prednisone for longer duration is fraught with unavoidable prednisone side effects.

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