Is prednisone safe to use during pregnancy?

Prednisone Safety During Pregnancy

Prednisone can be safely used during pregnancy, but should be limited to the minimum effective dose and preferably only for acute, widespread flares of disease. 1

Safety Profile and Recommendations

• Prednisone is classified as FDA Pregnancy Category C, meaning animal studies have shown potential risks but human studies are limited 2
• Guidelines from multiple specialties support the conditional use of prednisone during pregnancy:
  • Rheumatology guidelines recommend continuing low-dose glucocorticoid treatment (≤10 mg daily of prednisone) during pregnancy if clinically indicated 1
  • For higher doses, tapering to <20 mg daily is strongly recommended, adding pregnancy-compatible steroid-sparing agents if necessary 1
  • Hidradenitis suppurativa guidelines suggest using prednisone only for acute, widespread flares during pregnancy 1

Maternal Considerations

• Short-term, low-dose prednisone (10-20 mg/day) is generally considered effective and safe for pregnant women 1
• Higher doses or prolonged use may increase risks of:
  • Hypertension and preeclampsia
  • Hyperglycemia/gestational diabetes
  • Premature rupture of membranes 1
  • Shorter gestational age 3

Fetal Considerations

• Conflicting data exists regarding birth defects:
  • Some studies show no increased risk of birth defects in humans 1
  • Other studies indicate potential increased risk (3-fold) of isolated cleft lip/palate, especially during first trimester exposure 1
  • Higher prednisone dose trajectory groups are associated with reduced gestational age at delivery 3

Dosing and Monitoring

• Pharmacokinetics of prednisone change during pregnancy - clearance increases with dose 4
• Dose adjustments are necessary during pregnancy:
  • Use the minimum effective dose to control disease activity
  • For chronic conditions requiring immunosuppression, consider reducing dose by 25-50% of pre-pregnancy dose 1
  • Monitor disease activity and adjust accordingly

Breastfeeding Considerations

• Prednisone is considered compatible with breastfeeding:
  • Small amounts transfer into breast milk (relative infant dose 0.35-0.53%) 4
  • For doses <20 mg daily, breastfeeding is considered safe 1
  • For doses ≥20 mg daily, consider discarding breast milk obtained within 4 hours of taking medication 1

Disease-Specific Considerations

• For immune thrombocytopenia: Low-dose prednisone (10-20 mg/day) is effective and should be adjusted to minimum dose that produces hemostatic platelet count 5
• For autoimmune hepatitis: Prednisone alone can induce clinical, laboratory and histological improvements; low-dose therapy (median 7.5 mg daily) can suppress disease activity long-term 1
• For rheumatoid arthritis: Disease often improves during pregnancy due to hormonal changes, potentially allowing for dose reduction 6

Common Pitfalls to Avoid

1. Abrupt discontinuation - can lead to disease flare and adrenal insufficiency
2. Unnecessary high-dose therapy - use minimum effective dose
3. Failure to monitor for maternal complications (hypertension, hyperglycemia)
4. Overlooking the need for stress-dose steroids during labor and delivery if patient has been on long-term therapy
5. Not considering steroid-sparing agents when appropriate

Remember that the benefits of controlling severe maternal disease generally outweigh the potential risks of prednisone to the fetus, but each case should be evaluated based on disease severity, trimester of pregnancy, and available alternative treatments.