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Last updated: Dec 04, 2020
8 min read

Prednisone withdrawal: here’s what can happen

Abrupt discontinuation of prednisone can also cause steroid withdrawal syndrome. Steroid withdrawal syndrome may be related to adrenal insufficiency, but the causes aren’t fully understood.

Disclaimer

If you have any medical questions or concerns, please talk to your healthcare provider. The articles on Health Guide are underpinned by peer-reviewed research and information drawn from medical societies and governmental agencies. However, they are not a substitute for professional medical advice, diagnosis, or treatment.

What is prednisone?

Prednisone is a synthetic steroid hormone of a type known as glucocorticoids. Glucocorticoids such as cortisol are produced naturally in our bodies. This name derives from three things: they help regulate glucose metabolism, they’re created in the adrenal cortex, and they’re steroids (Puckett, 2020). While our adrenal glands obviously do not produce prescription synthetic glucocorticoids, they act in similar ways and have similar chemical structures.

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Prednisone may be prescribed to patients whose adrenal glands aren’t producing enough hormones on their own, a condition known as Addison’s disease. The FDA also approves prednisone for treating several autoimmune and inflammatory conditions, including (UpToDate, n.d.):

  • Acute allergic reactions
  • Acute asthma attacks
  • Inflammatory bowel diseases, such as Crohn’s disease or ulcerative colitis
  • Multiple sclerosis
  • Rheumatic disorders, such as rheumatoid arthritis and gout
  • Systemic lupus erythematosus
  • Immune thrombocytopenia, a condition that affects blood clotting
  • Warm autoimmune hemolytic anemia (WAHA)
  • Organ rejection after transplant 

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

Prednisone itself does nothing until it passes through the liver, which converts it into prednisolone. After that, it travels throughout the body, where it binds to glucocorticoid receptors. The primary effect this has is to suppress the immune system and reduce inflammation (Puckett, 2020). 

Prednisolone may also be introduced into the system with methylprednisolone, a different but similar medication. The main differences are that methylprednisolone is somewhat stronger and does not need the liver to break it down. It can be administered intravenously or directly to inflamed areas via injection (Ocejo, 2020). Methylprednisolone may also be taken orally and carries the same risks and potential side effects as prednisone.

Some long-term side effects of prednisone can be quite severe. Because of this, prednisone is usually prescribed for short-term use to treat acute (temporary) conditions or flare-ups of chronic disorders. When longer-term use is required, prescribers will find the lowest dose possible to achieve the desired effect (UpToDate, n.d.). For most patients, the side effects are less bothersome than the original condition.

Prednisone withdrawal symptoms can be quite dangerous, so withdrawal must be undertaken in a safe, measured manner. We’ll talk about the withdrawal process, possible symptoms of prednisone withdrawal, and why you should never take it upon yourself to stop treatment on your own. Abruptly stopping any corticosteroid treatment can be life-threatening. Always follow the medical advice of your healthcare provider when stopping any medication.

Prednisone withdrawal

One of the most severe potential complications when stopping prednisone therapy lies in your adrenal glands. When adding external glucocorticoids to your system, your adrenal cortex may lower or even stop cortisol production to compensate. If your body doesn’t have enough cortisol, this can lead to what’s called adrenal insufficiency, or in severe cases, adrenal crisis. Giving your adrenal glands time to readjust when stopping therapy is very important.

Adrenal insufficiency is quite variable. Some patients won’t experience it at all. Among those that do, it can take a few days to a few weeks for normal function to return after withdrawal is complete. For an unfortunate few, it can take months or even years for a full recovery. The severity of this does not always correlate with one’s dose or duration of use (Dinsen, 2013).

Some patients may have low cortisol production after withdrawal and not even realize it. The adrenal glands may produce just enough for typical daily activities. If a triggering event then occurs where more cortisol is needed, an adrenal crisis could occur.

Abrupt discontinuation of prednisone can also cause steroid withdrawal syndrome. Steroid withdrawal syndrome may be related to adrenal insufficiency, but the causes aren’t fully understood. Symptoms may include (Margolin, 2007):

  • Fever
  • Nausea
  • Severe fatigue
  • Body aches
  • Joint pain
  • Skin peeling
  • Weight loss
  • Loss of appetite
  • Abdominal pain
  • Postural hypotension (sudden low blood pressure when standing up)
  • Low sodium
  • Excessively high potassium

Your provider will likely prescribe a gradual reduction in dose over a week or two, or possibly longer. Not only for the above possibilities but to monitor for a return of the original condition as well. If you experience adverse reactions when tapering or symptoms of the original disease returning, talk to your healthcare provider.

The amount of time it takes to taper will depend on the dose you’ve been taking and the original condition, among other factors. Adrenal insufficiency can occur even with tapering, and your provider may wish to run tests if they detect potential signs.

For short courses lasting less than one week, tapering may not be necessary, even if taking high doses. For treatments lasting from one to three weeks, your healthcare provider will assess the underlying condition and your general health before coming up with a plan specific to you. After long courses lasting more than three weeks, tapering can last longer, even weeks. Some prescribers may wish to taper you down to very low doses and switch you to hydrocortisone, a less potent glucocorticoid, and taper further from there (Lansang, 2011).

Side effects

Side effects when taking prednisone are common. A survey of over 2,000 patients taking long-term corticosteroid therapy (more than 60 days) found that only 10% did not experience any side effects at all. The most common adverse 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)

Some adverse effects can appear even in short-term therapy. Other possible side effects of prednisone may include (MedlinePlus, 2020):

  • Headache
  • Dizziness
  • Insomnia
  • Extreme tiredness
  • Mood swings
  • Personality changes
  • Bulging eyes
  • Fast hair growth
  • Heartburn
  • Excessive sweating
  • Muscle weakness or pain
  • Menstruation irregularity or absence
  • Low libido
  • Acne
  • Blotches under the skin
  • Easily wounded skin
  • Slow-healing wounds
  • Changes to the distribution of body fat, especially in the face or upper back

Be sure to tell your healthcare provider if any of the above symptoms don’t go away on their own or are severe.

Some side effects can be signs of an allergic reaction or other dangerous conditions, such as Cushing’s syndrome, which is a response to too much glucocorticoid in your system. Tell your healthcare provider immediately if any of the following occur when taking prednisone (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 extremities
  • Upset stomach
  • Vomiting
  • Lightheadedness
  • Irregular heart rate
  • Sudden weight gain
  • Shortness of breath, especially at night
  • Dry, hacking cough
  • Abdominal pain or swelling

Because prednisone suppresses the immune system, it may affect your ability to fight infections. Avoid contact with sick people while taking prednisone, especially those with chickenpox or measles, if you have not had either before or are not vaccinated. Call your healthcare provider immediately if you believe you have been close to someone sick (DailyMed, 2019).

Never abruptly stop prednisone treatment or lower your dose on your own, whatever side effects you may be experiencing. Talk to your healthcare provider and follow their instructions.

Drug interactions

Tell your healthcare provider about all prescription drugs and over-the-counter medications you are taking, as well as any vitamins or supplements. Be sure to mention any of the following (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, also 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

Other precautions

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.

If you have any kind of surgery or medical treatment, including dental surgery, tell them that you are taking prednisone. Wear a bracelet or carry a card with this information in case of an emergency in which you can’t communicate.

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

The immunosuppressive effect of prednisone can limit your response to certain vaccines. Talk to your healthcare provider before having any vaccinations while taking prednisone (UpToDate, n.d.). 

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. They may instruct you to avoid grapefruit or grapefruit juice while taking prednisone (MedlinePlus, 2020).

Prednisone dosage, storage, and cost

Doses can vary widely. Depending on the medical condition, it can range from as low as 2.5 mg to as high as 200 mg daily. It may be taken as one dose or in multiple smaller doses throughout the day. Most prescriptions range from 10 mg to 60 mg per day. Courses usually last from two to three days up to two to three weeks to relieve acute (temporary) conditions. For long-term treatment of chronic diseases, your prescriber may start you at a higher dose for a short time before bringing you down to a lower maintenance dose (UpToDate, n.d.).

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. It is available in immediate or delayed-release tablets as well as liquid solutions. If your insurance does not cover it, the cost ranges from about $5 for 30 pills at 2.5 mg to around $10 for the same amount at 50 mg (GoodRx, n.d.

References

  1. Curtis, J. R., Westfall, A. O., Allison, J., Bijlsma, J. W., Freeman, A., George, V., Kovac, S. H., Spettell, C. M., & Saag, K. G. (2006). Population-based assessment of adverse events associated with long-term glucocorticoid use. Arthritis & Rheumatism, 55(3), 420–426. doi:10.1002/art.21984 Retrieved from https://pubmed.ncbi.nlm.nih.gov/16739208/
  2. DailyMed (n.d.) Prednisone tablet Retrieved 13 December 2020 from https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=d4b46716-044d-4213-8030-950affa41c3b
  3. Dinsen, S., Baslund, B., Klose, M., Rasmussen, A. K., Friis-Hansen, L., Hilsted, L., & Feldt-Rasmussen, U. (2013). Why glucocorticoid withdrawal may sometimes be as dangerous as the treatment itself. European Journal of Internal Medicine, 24(8), 714–720. doi:10.1016/j.ejim.2013.05.014 Retrieved from https://pubmed.ncbi.nlm.nih.gov/23806261/
  4. GoodRx (n.d.) Prednisone Generic Deltasone, Sterapred. Generated interactively: Retrieved 07 December 2020 from https://www.goodrx.com/prednisone
  5. Lansang, M. C., & Hustak, L. K. (2011). Glucocorticoid-induced diabetes and adrenal suppression: How to detect and manage them. Cleveland Clinic Journal of Medicine, 78(11), 748–756. doi:10.3949/ccjm.78a.10180 Retrieved from https://pubmed.ncbi.nlm.nih.gov/22049542/
  6. Margolin, L., Cope, D. K., Bakst-Sisser, R., & Greenspan, J. (2007). The steroid withdrawal syndrome: A review of the implications, etiology, and treatments. Journal of Pain and Symptom Management, 33(2), 224–228. doi:10.1016/j.jpainsymman.2006.08.013 Retrieved from https://pubmed.ncbi.nlm.nih.gov/17280928/
  7. MedlinePlus (2020). Prednisone. Retrieved 07 December 2020, from https://medlineplus.gov/druginfo/meds/a601102.html
  8. Ocejo A, Correa R. Methylprednisolone. [Updated 2020 Oct 12]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Retrieved from: https://www.ncbi.nlm.nih.gov/books/NBK544340/
  9. Puckett Y, Gabbar A, Bokhari AA. Prednisone. [Updated 2020 Apr 22]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Retrieved from: https://www.ncbi.nlm.nih.gov/books/NBK534809/
  10. UpToDate Prednisone: Drug information (n.d.). Retrieved 07 December 2020 from https://www.uptodate.com/contents/prednisone-drug-information