Can prednisone (corticosteroid) increase blood pressure?

Prednisone's Effect on Blood Pressure

Yes, prednisone can significantly increase blood pressure through several mechanisms, particularly at higher doses and with longer duration of use. 1 The FDA drug label for prednisone specifically lists elevation of blood pressure among its cardio-renal effects, noting that corticosteroids can cause salt and water retention.

Mechanisms of Prednisone-Induced Hypertension

Prednisone and other corticosteroids can increase blood pressure through multiple pathways:

1. Mineralocorticoid effects:

   • Salt and water retention
   • Increased plasma volume
   • Increased sodium levels 1

2. Direct vascular effects:

   • Increased vascular sensitivity to vasoconstrictors
   • Decreased vasodilation 2

3. Sympathetic nervous system activation:

   • Increased low-frequency component of systolic blood pressure variability, suggesting sympathetic stimulation 3

Dose and Duration Relationship

The hypertensive effect of prednisone appears to be:

• Dose-dependent: Higher doses are more likely to cause significant blood pressure elevation 1
• Time-variable: Effects can occur:
  • During active treatment
  • During reduction of long-term therapy 4
  • Within days of starting treatment 3, 5

Evidence from Clinical Studies

Research demonstrates varying effects on blood pressure:

• A study using synthetic glucocorticoids (including prednisolone) showed significant blood pressure increases of 6-13 mmHg systolic and 7-11 mmHg diastolic after just 5 days of treatment, even without mineralocorticoid activity or plasma volume expansion 2

• A 1-week prednisone administration study showed slight increases in heart rate and low-frequency power of systolic blood pressure variability 3

• A 4-day prednisolone treatment study demonstrated significantly higher 24-hour systolic, diastolic, and mean blood pressures, with particularly elevated sleeping systolic and mean blood pressures 5

• Interestingly, one study of long-term low-dose corticosteroid therapy found no significant relationship between blood pressure changes and either dose or duration of therapy 6

Special Considerations

1. Withdrawal phase: Patients may develop hypertension during corticosteroid reduction, not just during maximum dosing. In one study of young asthma patients, maximum diastolic pressures of 100-120 mmHg occurred 1-8 weeks after starting corticosteroid reduction 4

2. Monitoring requirements: The FDA drug label recommends frequent measurements of blood pressure, particularly in pediatric and elderly patients 1

3. Risk factors: Elderly patients have an increased risk of hypertension with corticosteroid treatment 1

Management Approach

For patients requiring prednisone:

1. Monitor blood pressure regularly during both treatment and tapering phases
2. Use lowest effective dose for shortest duration possible
3. Consider alternative formulations (local steroid injections) when appropriate
4. Be vigilant during tapering, as hypertension may paradoxically worsen during reduction phase
5. Consider antihypertensive therapy if blood pressure elevation is significant:
   • ACE inhibitors may be particularly effective for steroid-induced hypertension 4
   • Diuretics may be less effective 4

Conclusion

Prednisone has a well-documented effect on blood pressure through multiple mechanisms. Clinicians should monitor blood pressure closely in all patients on prednisone therapy, particularly during dose changes and in vulnerable populations like the elderly.