What are the long-term side effects of taking prednisone (corticosteroid) and how can they be managed?

Long-Term Side Effects of Prednisone and Their Management

Long-term prednisone use causes significant side effects including osteoporosis, weight gain, hypertension, diabetes, cataracts, and mood disturbances, which should be actively monitored and managed with preventive strategies including calcium/vitamin D supplementation, bone density monitoring, and consideration of steroid-sparing agents whenever possible.

Common Long-Term Side Effects

Musculoskeletal Effects

• Osteoporosis and increased fracture risk are among the most serious complications of long-term corticosteroid therapy, with bone loss occurring soon after initiation of therapy 1, 2
• Even low doses of prednisone (5 mg daily) can suppress bone formation markers, suggesting potential adverse effects on bone mass and strength 3
• Avascular necrosis of bone can occur with prolonged use 4

Metabolic and Endocrine Effects

• Weight gain, facial rounding (moon face), and fluid retention are common cosmetic changes 1, 4
• Hyperglycemia and worsening of diabetes require regular blood glucose monitoring 1, 5
• Dyslipidemia can develop with prolonged use 4
• Adrenal suppression can occur, leading to dependency on corticosteroids 5

Cardiovascular Effects

• Hypertension can develop or worsen, requiring regular blood pressure monitoring 1, 5
• Increased risk of cardiovascular disease due to metabolic effects 4

Neuropsychiatric Effects

• Mood disturbances ranging from euphoria to depression, with sleep disturbances occurring in >30% of patients 1
• Emotional instability, personality changes, and even psychotic manifestations can occur 5

Ocular Effects

• Cataracts, including posterior subcapsular cataracts, develop with prolonged use 1, 5
• Increased intraocular pressure and glaucoma require monitoring if therapy continues beyond 6 weeks 5

Other Effects

• Increased susceptibility to infections, including opportunistic infections 4
• Skin changes including thinning, striae, and purpura 1
• Growth retardation in children 4

Risk Factors for Side Effects

• Higher doses (>20 mg/day) and longer duration (>18 months) significantly increase the risk of severe adverse effects 4, 1
• Pre-existing conditions such as diabetes, hypertension, or osteoporosis 4
• Age (elderly and children are more vulnerable) 4
• Additional risk factors for osteoporosis include smoking, excessive alcohol consumption, immobilization, and hypogonadism 2

Management Strategies

Bone Health Management

• Baseline and annual bone mineral density testing of the lumbar spine and hip for patients on long-term therapy 4
• Calcium (1000 mg/day) and vitamin D (400-800 IU/day) supplementation for all patients on long-term therapy 5, 2
• Consider bisphosphonates for high-risk patients or those with established osteoporosis 2, 6
• Regular weight-bearing exercise to maintain muscle mass and bone density 5, 2
• Consider thiazide diuretics if hypercalciuria is present 2

Metabolic Management

• Regular monitoring of blood glucose levels and blood pressure 1, 5
• Lifestyle modifications including diet control and regular exercise 5
• Consider antidiabetic medication adjustments as needed 5

Infection Prevention

• Update vaccines before beginning immunosuppressant therapy 4
• Consider Pneumocystis prophylaxis (e.g., trimethoprim-sulfamethoxazole) for patients taking ≥20 mg prednisone for ≥4 weeks 4

Ocular Health

• Regular eye examinations for cataracts and glaucoma, especially if therapy continues beyond 6 weeks 5

Medication Strategy

• Use the lowest effective dose for the shortest duration possible 1, 4
• Consider combination therapy with steroid-sparing agents like azathioprine to reduce corticosteroid dose requirements 4
• The combination regimen of prednisone and azathioprine is associated with a lower occurrence of corticosteroid-related side effects (10%) than prednisone alone (44%) 4
• Consider budesonide plus azathioprine in non-cirrhotic patients to reduce systemic steroid side effects 4
• Never discontinue prednisone abruptly due to risk of adrenal insufficiency 5

Special Considerations

Children

• Growth monitoring is essential in pediatric patients 4
• Early use of steroid-sparing agents is recommended to minimize growth effects 4
• Consider alternate-day regimens to reduce side effects, though this may reduce immunosuppression 4

Elderly

• Higher risk of osteoporosis, hypertension, and diabetes requires more vigilant monitoring 4
• Consider lower starting doses and more gradual tapering 4

Pregnancy

• Prednisone monotherapy is preferred over combination therapy during pregnancy 4

Reversibility of Side Effects

• Some side effects, particularly bone loss, may be partially reversible after discontinuation of therapy, especially in younger patients 7
• Recovery potential may be reduced in elderly patients 7