Prednisone side effects: what to be aware of

Prednisone is a type of drug called a corticosteroid, more specifically a glucocorticoid. This name comes from the fact that they help regulate glucose metabolism, are manufactured in the adrenal cortex and are steroids. 

Prednisone is first converted to prednisolone in the liver, after which it can bind to glucocorticoid receptors throughout our bodies. This suppresses the immune system and has anti-inflammatory effects (Puckett, 2020). 

Prednisone is not to be confused with the similarly named methylprednisolone, although they are closely related and are used to treat the same conditions and can have the same side effects.

The FDA has approved prednisone for the treatment of adrenal insufficiency, also known as Addison's disease. Addison's disease is when the adrenal glands don't produce enough hormones on their own. It is also approved for the treatment of numerous autoimmune and inflammatory conditions, including (UpToDate, n.d.):

• Acute allergic reactions

• Acute asthma attacks

• Immune thrombocytopenia, a condition that affects blood clotting

• Inflammatory bowel diseases, such as Crohn's disease or ulcerative colitis

• Multiple sclerosis

• Rheumatic disorders, such as rheumatoid arthritis and gout

• Systemic lupus erythematosus

• Warm autoimmune hemolytic anemia (WAHA)

Prednisone may be prescribed off-label as well for other conditions, including (UpToDate, n.d.):

• Bell's palsy

• Chronic obstructive pulmonary disease (COPD)

• Coronavirus disease 2019 (COVID-19)

• Giant cell arteritis, an inflammation of blood vessels around the scalp

• Autoimmune hepatitis

• Certain cancers, including prostate cancer and multiple myeloma

In most cases, prednisone is prescribed for short-term use to treat acute (temporary) conditions or flare-ups of chronic disorders. Long-term use of synthetic corticosteroids can cause the adrenal cortex to stop producing natural ones on its own.

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Side effects are common. One survey of over 2,000 patients taking corticosteroids long-term found that only 10% of them did not experience any adverse effects at all. The most common side effects reported were (Curtis, 2006):

• Weight gain

• Skin thinning or bruising

• Trouble sleeping

• Mood problems

• Cataracts

• Acne

• Bone fractures

• High blood sugar (in non-diabetics)

In most cases, patients taking high doses or longer courses were more at risk. In the above survey, "long-term" was defined as any course over 60 days. 

For the effects of long-term use, researchers often look at the total cumulative dose. For example, this study was broken into four groups. The lowest cumulative dose group ("Q1") were patients taking less than or equal to 10 mg per day for six months. This would include those taking up to 5 mg per day for 12 months and those taking 20 mg per day for three months. The highest cumulative dose group ("Q4") were patients taking greater than or equal to 10 mg per day for 18 months. 

The differences in adverse effects across the groups were significant. Skin bruising and thinning showed the most extreme difference, being three times more likely in the highest cumulative dose group than the lowest. Sleep disturbance, weight gain, and moodiness were all found to be over twice as likely in the high dose group versus the lowest (Curtis, 2006).

Bone fracture is one of the most significant long-term risks of corticosteroid use, especially among older patients. High doses or long-term use of prednisone may increase the risk of developing osteoporosis (bone loss). Patients with a higher risk for osteoporosis due to age, family history, or other conditions should discuss this with their provider (UpToDate, n.d.). 

Studies have demonstrated that supplementing prednisone with a combination of calcium and vitamin D can offset bone density loss in many patients, especially in the lower spine and forearm (Homik, 1998).

Some side effects are not necessarily cumulative and can appear even within a day of starting prednisone therapy. Possible side effects of prednisone, even with short term use, may include (MedlinePlus, 2020):

• Headache

• Dizziness

• Insomnia

• Extreme tiredness

• Mood changes, severe mood swings

• Inappropriate happiness

• Personality changes

• Bulging eyes

• Faster hair growth

• Heartburn

• Increased sweating

• Muscle weakness

• Muscle pain

• Menstruation irregularity or absence

• Low sexual desire

• Skin conditions such as acne, blotches under the surface, slower wound healing, and more easily wounded skin

• Lipodystrophy, or changes to the distribution of body fat, especially in the face (commonly called "moon face") or upper back (commonly called "buffalo hump") (Nishioka, 2019)

Be sure to tell your healthcare provider if any of the above symptoms don't go away on their own or are severe. Some could be indications of other developing conditions. For example, in one study, corticosteroid-induced lipodystrophy (CIL) during long-term treatment appeared to correlate with an increased risk of high blood pressure, among other conditions (Fardet, 2007).

Serious side effects can be signs of a more severe problem, such as an allergic reaction or Cushing's syndrome, a response to too much glucocorticoid in your system. Tell your prescriber immediately if any of the following occur (MedlinePlus, 2020):

• Eye pain, redness, or tearing

• Vision problems

• Swelling in the eyes, face, lips, tongue, throat

• Swelling in the arms, hands, feet, ankles, or lower legs

• Difficulty breathing or swallowing

• Skin rash, hives, or itching

• Sore throat, fever, chills, cough, or other signs of infection

• Seizures

• Depression

• Delusion

• Confusion

• Muscle spasms or tightening

• Uncontrollable shaking of the hands

• Numbness, burning, or tingling in the face, arms, legs, feet, or hands

• Upset stomach

• Vomiting

• Lightheadedness

• Irregular heartbeat

• Sudden weight gain

• Shortness of breath, especially at night

• Dry, hacking cough

• Abdominal pain or swelling

Never abruptly stop prednisone treatment or lower your dose on your own. Always follow the medical advice of your healthcare provider. In most cases, they will reduce your dose in a gradual, safe manner.

Abrupt discontinuation of any steroid therapy can cause steroid withdrawal syndrome. Symptoms can be more severe than the side effects. Steroid withdrawal symptoms may include (Margolin, 2007):

• Fever

• Nausea

• Lethargy

• General discomfort

• Joint pain

• Skin peeling

• Weight loss

• Anorexia

• Abdominal pain

• Postural hypotension (sudden drop in blood pressure when standing up)

• Low sodium

• Overly high potassium

Tell your healthcare provider about all prescription drugs and over-the-counter medications you are taking, as well as any vitamins or supplements. The following are especially important (MedlinePlus, 2020):

• Amiodarone (brand name Pacerone)

• Anticoagulants (blood thinners) such as warfarin (brand name Coumadin)

• Antifungals such as fluconazole (brand name Diflucan), itraconazole (brand name Sporanox), ketoconazole (brand name Nizoral), and voriconazole (brand name Vfend)

• Aprepitant (brand name Emend)

• Aspirin

• Carbamazepine (brand names Carbatrol, Epitol, Tegretol)

• Cimetidine (brand name Tagamet)

• Clarithromycin (brand name Biaxin, or as part of the combination pack Prevpac)

• Cyclosporine (brand names Neoral, Sandimmune)

• Delavirdine (brand name Rescriptor)

• Diltiazem (brand names Cardizem, Dilacor, Tiazac)

• Dexamethasone (brand names Decadron, Dexpak)

• Diuretics (water pills)

• Efavirenz (brand name Sustiva)

• Fluoxetine (brand name Prozac, Sarafem)

• Fluvoxamine (brand name Luvox)

• Griseofulvin (brand names Fulvicin, Grifulvin, Gris-PEG)

• HIV protease inhibitors including atazanavir (brand name Reyataz), indinavir (brand name Crixivan), lopinavir (in brand name Kaletra), nelfinavir (brand name Viracept), ritonavir (brand name Norvir, or in Kaletra), and saquinavir (brand names Fortovase, Invirase)

• Hormonal contraceptives, such as birth control pills, patches, rings, implants, or injections

• Lovastatin (brand names Altocor, Mevacor)

• Diabetes medications

• Nefazodone

• Nevirapine (brand name Viramune)

• Phenobarbital

• Phenytoin (brand names Dilantin, Phenytek)

• Rifabutin (brand name Mycobutin)

• Rifampin (brand names Rifadin, Rimactane, also part of Rifamate)

• Sertraline (brand name Zoloft)

• Troleandomycin (brand name TAO)

• Verapamil (brand names Calan, Covera, Isoptin, Verelan)

• Zafirlukast (brand name Accolate)

• St. John's wort

Some drugs may not be combined with prednisone. Others may but might require an increase or decrease in your dose. Your prescriber may wish to monitor you for specific side effects when taking certain medications with prednisone. 

Before taking prednisone, be sure to tell your healthcare provider if you have or have had any of the following conditions (MedlinePlus, 2020):

• An allergy to prednisone, or any medication or its ingredients

• A current eye infection, or eye infections that come and go

• Threadworms (a type of worm that can live inside the body)

• Diabetes

• High blood pressure

• A psychiatric condition

• Myasthenia gravis (a condition in which the muscles become weak)

• Osteoporosis

• Seizures

• Tuberculosis (TB)

• Ulcers

• Liver, kidney, intestinal, heart, or thyroid disease

Tell your prescriber if you are pregnant, could become pregnant, or are nursing before starting prednisone, or if you become pregnant while taking it. Prednisone is generally considered safe in low doses for pregnant or nursing women. Still, higher doses may temporarily reduce milk supply (LactMed, n.d.).

If you are having any kind of surgery or medical treatment, including dental, be sure to tell the medical staff that you are taking prednisone. Wear a bracelet or carry a card with this information in case of an emergency where you can't communicate.

If you have any kind of skin test, such as an allergy test, tell the technician you are taking prednisone.

Because prednisone suppresses the immune system, it may lower your ability to fight infections. Since many infection symptoms are the result of immune system reactions, it can effectively hide the disease. The immunosuppression can also limit your response to certain vaccines. Talk to your healthcare provider before having any vaccinations while taking prednisone (UpToDate, n.d.). 

Avoid contact with people who are sick while taking prednisone and wash your hands frequently. Take special care to avoid contact with people who have chickenpox or measles, especially if you are not immunized or have not had either disease before. Chickenpox and measles can be fatal in non-immune patients taking corticosteroids. Call your healthcare provider immediately if you think you may have been near someone sick (DailyMed, 2019).

Your prescriber may recommend specific dietary changes, such as a low-salt, high-potassium, or high-calcium diet, or prescribe you calcium or potassium supplements. In some instances, they may instruct you to avoid grapefruit or grapefruit juice while taking it (MedlinePlus, 2020).

Doses can vary widely, from as low as 2.5 mg up to 200 mg daily. For most conditions, prescriptions typically range from 10 mg to 60 mg per day. It may be taken as one dose or in multiple smaller doses throughout the day. 

For relief of acute (temporary) conditions, courses can last from two to three days up to two to three weeks, followed by up to a week of tapering down (UpToDate, n.d.). It is available in immediate or delayed-release tablets as well as liquid solutions. Your prescriber will determine which form is right for you. 

Keep prednisone out of sight and reach of children, sealed, in its original container. Do not store prednisone in a room with possible excess heat or moisture, such as a bathroom. 

Prednisone is inexpensive. If not covered by your insurance, the cost can range from just over $5.00 for 30 pills at 2.5 mg to around $10 for the same number at 50 mg (GoodRx, n.d.) 

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Current version

May 05, 2021

Written by

Seth Gordon

Fact checked by

Mike Bohl, MD, MPH, ALM

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About the medical reviewer

Mike Bohl, MD, MPH, ALM

Dr. Mike is a licensed physician and a former Director, Medical Content & Education at Ro.