Prednisone Side Effects
Prednisone has numerous adverse effects including cosmetic changes (weight gain, facial rounding, hirsutism), metabolic disturbances (glucose intolerance/diabetes), cardiovascular effects (hypertension), bone health impacts (osteoporosis), mood disturbances, and increased infection risk. 1, 2
Common Side Effects
Cosmetic Effects
- Facial rounding (moon face)
- Weight gain and increased appetite
- Hirsutism (excessive hair growth)
- Acne and skin changes
- Striae (stretch marks)
- Dorsal hump (buffalo hump)
- Alopecia (hair loss)
Metabolic and Endocrine Effects
- Glucose intolerance and diabetes
- Adrenal suppression (particularly with doses >10 mg daily for >3 weeks)
- Fluid retention and bloating
- Hypokalemia (potassium loss)
- Sodium retention with resulting edema
- Negative nitrogen balance due to protein catabolism
Cardiovascular Effects
- Hypertension
- Edema
- Increased risk of atherosclerosis with long-term use
- Potential for aortic complications with prolonged use (≥7.5 mg daily)
Musculoskeletal Effects
- Osteoporosis and increased fracture risk (can occur within 3 months of starting therapy)
- Vertebral compression fractures
- Aseptic necrosis of femoral and humeral heads
- Muscle weakness and steroid myopathy
- Tendon rupture
Neuropsychiatric Effects
- Insomnia
- Mood changes (emotional instability, irritability)
- Depression or euphoria
- Anxiety
- Psychosis (in severe cases)
Gastrointestinal Effects
- Gastric irritation
- Peptic ulcer with possible perforation and hemorrhage
- Nausea
- Increased appetite
Immune System Effects
- Increased risk of infections (bacterial, viral, fungal)
- Reactivation of latent infections (e.g., tuberculosis, hepatitis B)
- Masking of infection signs
Ocular Effects
- Cataracts (posterior subcapsular)
- Glaucoma
- Increased intraocular pressure
Risk Factors and Dose Considerations
The severity of side effects depends on several factors:
- Dose: Higher doses (>10 mg daily) significantly increase risk of adverse effects 1
- Duration: Side effects are more common with treatment >2 weeks 3
- Pre-existing conditions: Patients with diabetes, osteoporosis, glaucoma, or hypertension are at higher risk 4
Prevention and Management
Bone Health
- Calcium supplementation (800-1000 mg daily)
- Vitamin D (800 IU daily)
- Baseline bone mineral density testing before or within 1 month of starting therapy
- Consider bisphosphonates for high-risk patients 4
Adrenal Suppression
- Gradual tapering when discontinuing therapy
- Monitor for withdrawal symptoms (weakness, fatigue, nausea)
- Consider stress-dose steroids during illness or surgery if on long-term therapy 2
Metabolic Monitoring
- Regular blood glucose monitoring
- Blood pressure checks
- Potassium monitoring
- Consider lifestyle interventions for metabolic syndrome 1
Infection Prevention
- Complete immunizations before starting therapy
- Consider prophylactic medications for high-risk patients
- Monitor for signs of infection 4
Special Considerations
Duration of Treatment
- Whenever possible, use the lowest effective dose for the shortest duration
- Prolonged prednisone monotherapy, especially at doses >10 mg daily, should be avoided 1
- Consider alternate-day dosing to reduce side effects when appropriate 1
Combination Therapy
- Using prednisone with steroid-sparing agents may allow for lower steroid doses
- The combination regimen with azathioprine is associated with much lower occurrence of corticosteroid-related adverse events 1
Conclusion
While prednisone is effective for many inflammatory conditions, its side effect profile requires careful monitoring and preventive measures. The risk-benefit ratio should be evaluated regularly, with efforts to minimize dose and duration of therapy whenever possible.