Long-Term Prednisone Use Side Effects
Long-term prednisone use can cause numerous serious side effects including adrenal suppression, osteoporosis, diabetes, hypertension, cataracts, increased infection risk, and cardiovascular complications. 1
Major Systemic Side Effects
Endocrine and Metabolic Effects
- Adrenal axis suppression: Can occur with prolonged use, leading to inability to respond to stress 2, 1
- Cushing syndrome: Moon face, buffalo hump, central obesity 2
- Glucose metabolism: Hyperglycemia, diabetes mellitus, worsening of existing diabetes 1, 2
- Weight gain: Due to increased appetite and fluid retention 2, 1
- Lipid abnormalities: Dyslipidemia 1
Musculoskeletal Effects
- Osteoporosis: Even low doses (5 mg daily) can suppress bone formation 3
- Avascular necrosis: Particularly of femoral and humeral heads 1
- Muscle weakness/myopathy: Due to protein catabolism 1
Cardiovascular Effects
- Hypertension: Due to salt and water retention 1
- Increased risk of myocardial infarction: Including left ventricular free wall rupture after recent MI 1
- Fluid retention and edema: Due to sodium retention 1
- Increased mortality: A study in IBD patients showed increased mortality with prolonged steroid use 2
Immunologic Effects
Ocular Effects
- Cataracts: Particularly posterior subcapsular cataracts 1, 5
- 30% of children on long-term prednisone developed posterior subcapsular cataracts 5
- Glaucoma: Due to increased intraocular pressure 1
- Regular eye examinations are recommended for patients on long-term therapy 2
Dermatologic Effects
- Skin thinning and atrophy: Leading to easy bruising 1
- Striae: Stretch marks on skin 1
- Acne: Particularly facial 1
- Hirsutism: Excessive hair growth 1
- Impaired wound healing: Due to collagen synthesis inhibition 1
Gastrointestinal Effects
- Peptic ulcer disease: Increased risk when combined with NSAIDs 1
- Gastrointestinal bleeding: Especially in patients with risk factors 6
- Pancreatitis: Rare but serious complication 1
Neuropsychiatric Effects
- Mood changes: Including euphoria, depression, emotional lability 1
- Sleep disturbances: Insomnia 1
- Psychosis: In susceptible individuals 1
- Cognitive changes: Memory impairment, difficulty concentrating 1
Dose-Dependent Risks
The risk of adverse effects increases with:
- Higher doses: Doses >10 mg daily have significantly higher risk 2, 6
- Longer duration: Severe complications typically develop after 18 months of continuous therapy 2
A study found that prednisone doses of 5-10 mg daily increased adverse event risk (OR=4.5), while doses of 10-15 mg daily dramatically increased risk (OR=32.3) 6
Special Considerations
Children
- Growth suppression: Can affect final adult height 2, 1
- Delayed puberty: Due to hormonal effects 1
- Monitoring: Regular growth assessment is essential 2
Elderly
- Increased susceptibility: To all adverse effects, particularly osteoporosis 1
- Higher fracture risk: Due to age-related bone loss compounded by steroid effects 7
Prevention Strategies
Bone Health
- Calcium and vitamin D supplementation: 800 IU vitamin D and 500-1000 mg calcium daily 2, 7
- Bisphosphonates: First-line therapy for prevention of steroid-induced osteoporosis 7
- Bone density monitoring: Regular assessment with DEXA scans 2
Infection Prevention
- Vaccination: Update vaccines before starting therapy 2
- Pneumocystis prophylaxis: Consider for doses ≥20 mg for ≥4 weeks 2
- Monitoring: For signs of infection during therapy 1
Adrenal Function
- Gradual tapering: Never stop prednisone abruptly 1
- Stress dosing: Increase dose during illness, surgery, or other stressors 1
Conclusion
Long-term prednisone use carries significant risks that increase with dose and duration. The FDA label clearly outlines these risks 1, and multiple guidelines recommend using the lowest effective dose for the shortest possible time 2. When long-term therapy is unavoidable, preventive measures should be implemented to minimize complications.