From the Guidelines
Prednisone at a dose of 5 milligrams is not considered an immunosuppressant according to the most recent guidelines. The ECCO guidelines on the prevention, diagnosis, and management of infections in inflammatory bowel disease, published in 2021 1, provide a framework for assessing the degree of immunosuppression associated with various therapeutic agents. According to these guidelines, systemic steroids like prednisone are considered to cause moderate-severe immunosuppression only at doses of ≥20 mg for >2 weeks. In contrast, doses of <5 mg/day are associated with a relative risk for infections of 1.10, which is significantly lower.
Key Points to Consider
- The degree of immunosuppression depends on the dose, duration, and route of administration of the therapeutic agent.
- Prednisone at 5mg daily is below the threshold for moderate-severe immunosuppression.
- Patients on low-dose prednisone should still be monitored for potential side effects and increased susceptibility to infections, although the risk is lower compared to higher doses.
- Regular monitoring by a healthcare provider is crucial for patients on long-term prednisone therapy, even at low doses, to manage potential side effects such as bone density loss, elevated blood sugar, and adrenal suppression.
Clinical Implications
The distinction between different degrees of immunosuppression has direct clinical implications, including the administration of live vaccines. While live vaccines are contraindicated in patients with moderate-severe immunosuppression, their administration can be considered on a case-by-case basis for patients with low-degree immunosuppression, if the benefit outweighs the risk 1. However, for prednisone at 5mg, the immunosuppressive effect is minimal, and thus, it does not significantly impact the decision to administer live vaccines based on the degree of immunosuppression alone.
From the FDA Drug Label
Corticosteroids, including prednisone tablets, suppress the immune system and increase the risk of infection with any pathogen, including viral, bacterial, fungal, protozoan, or helminthic pathogens
The rate of infectious complications increases with increasing corticosteroid dosages.
Immunosuppression is a known effect of prednisone, as it suppresses the immune system and increases the risk of infection. However, the dose of 5 milligrams is considered a low dose.
- The label does not specify a dose at which prednisone becomes an immunosuppressant.
- It does state that the rate of infectious complications increases with increasing corticosteroid dosages. Given this information, it can be inferred that prednisone (5 milligrams) has the potential to be an immunosuppressant, but the degree of immunosuppression may be less than with higher doses 2.
From the Research
Immunosuppressive Effects of Prednisone
- Prednisone is classified as an immunosuppressant due to its ability to repress the genomic expression by transcriptional interference, inhibiting proinflammatory proteins such as COX-2, IL-1, IL-2, IL-6, TNFalpha, and adhesion molecules 3.
- The drug is used in various autoimmune conditions, including myasthenia gravis, rheumatoid arthritis, and as part of immunosuppressive protocols in solid organ transplantation 4, 5, 6.
- Low doses of prednisone, such as 5 milligrams, have been shown to be effective in controlling inflammatory features of early polyarticular rheumatoid arthritis and retarding bony damage 3.
Mechanism of Action
- Prednisone acts as an immunosuppressant by inhibiting the activation of T cells and reducing the production of proinflammatory cytokines 4, 6.
- The drug is often used in combination with other immunosuppressants, such as azathioprine and cyclosporine, to achieve optimal immunosuppressive effects 5, 7.
Clinical Applications
- Prednisone is commonly used as a first-line immunosuppressant in the treatment of myasthenia gravis, with azathioprine and other immunosuppressants used as alternative or adjunctive therapies 4, 6.
- In rheumatoid arthritis, low-dose prednisone has been shown to be effective in controlling inflammatory symptoms and retarding disease progression 3.
- In solid organ transplantation, prednisone is often used as part of a triple-drug immunosuppressive regimen, along with cyclosporine and azathioprine, to reduce the risk of rejection and improve graft survival 5, 7.