What are the side effects of Prednisone (corticosteroid)?

From the Guidelines

Prednisone can cause numerous side effects, including cosmetic, systemic, and quality of life issues, such as facial rounding, weight gain, glucose intolerance, hypertension, and emotional instability, as outlined in the 2020 guidelines from the American Association for the Study of Liver Diseases 1.

Common Side Effects

• Increased appetite and weight gain
• Fluid retention and mood changes (including irritability, anxiety, and euphoria)
• Insomnia and elevated blood sugar levels
• Facial swelling (moon face), acne, and increased susceptibility to infections
• Digestive issues like heartburn or nausea

Serious Side Effects

• High blood pressure and diabetes
• Osteoporosis (bone thinning) and vertebral compression
• Cataracts and glaucoma
• Muscle weakness and thinning of the skin with easy bruising

Management Options

• Actively taper to the lowest steroid dose needed for remission and attempt withdrawal after remission
• Eye examinations for cataract and glaucoma
• Lifestyle interventions for metabolic syndrome
• Bone density monitoring and vitamin D and calcium administration
• Proactive screening and management for quality of life and mental health symptoms According to the guidelines, the risk and severity of side effects generally increase with higher doses and longer duration of treatment 1. Patients should report concerning side effects to their healthcare provider promptly. The 2020 guidelines provide the most recent and highest quality evidence for the management of autoimmune hepatitis, including the use of prednisone and its potential side effects 1.

From the FDA Drug Label

The following adverse reactions have been reported with prednisone or other corticosteroids: Allergic Reactions anaphylactoid or hypersensitivity reactions, anaphylaxis, angioedema Cardiovascular System bradycardia, cardiac arrest, cardiac arrhythmias, cardiac enlargement, circulatory collapse, congestive heart failure, ECG changes caused by potassium deficiency, edema, fat embolism, hypertension or aggravation of hypertension, hypertrophic cardiomyopathy in premature infants, myocardial rupture following recent myocardial infarction, necrotizing angiitis, pulmonary edema, syncope, tachycardia, thromboembolism, thrombophlebitis, vasculitis Dermatologic acne, acneiform eruptions, allergic dermatitis, alopecia, angioedema, angioneurotic edema, atrophy and thinning of skin, dry scaly skin, ecchymoses and petechiae (bruising), erythema, facial edema, hirsutism, impaired wound healing, increased sweating, Karposi’s sarcoma, lupus erythematosus-like lesions, perineal irritation, purpura, rash, striae, subcutaneous fat atrophy, suppression of reactions to skin tests, striae, telangiectasis, thin fragile skin, thinning scalp hair, urticaria Endocrine amenorrhea, postmenopausal bleeding or other menstrual irregularities, decreased carbohydrate and glucose tolerance, development of cushingoid state, diabetes mellitus (new onset or manifestations of latent), glycosuria, hyperglycemia, hypertrichosis, hyperthyroidism, hypothyroidism, increased requirements for insulin or oral hypoglycemic agents in diabetics, lipids abnormal, moon face, negative nitrogen balance caused by protein catabolism, secondary adrenocortical and pituitary unresponsiveness Fluid and Electrolyte Disturbances congestive heart failure in susceptible patients, fluid retention, hypokalemia, hypokalemic alkalosis, metabolic alkalosis, hypotension or shock-like reaction, potassium loss, sodium retention with resulting edema Gastrointestinal abdominal distention, abdominal pain, anorexia which may result in weight loss, constipation, diarrhea, elevation in serum liver enzyme levels (usually reversible upon discontinuation), gastric irritation, hepatomegaly, increased appetite and weight gain, nausea, oropharyngeal candidiasis, pancreatitis, peptic ulcer with possible perforation and hemorrhage, perforation of the small and large intestine, ulcerative esophagitis, vomiting Hematologic anemia, neutropenia (including febrile neutropenia) Metabolic negative nitrogen balance due to protein catabolism Musculoskeletal arthralgias, aseptic necrosis of femoral and humeral heads, increase risk of fracture, loss of muscle mass, muscle weakness, myalgias, osteopenia, osteoporosis, pathologic fracture of long bones, steroid myopathy, tendon rupture, vertebral compression fractures Neurologic convulsions, delirium, dementia, depression, dizziness, EEG abnormalities, emotional instability and irritability, euphoria, hallucinations, headache, impaired cognition, incidence of severe psychiatric symptoms, increased intracranial pressure with papilledema, increased motor activity, insomnia, ischemic neuropathy, long-term memory loss, mania, mood swings, neuritis, neuropathy, paresthesia, personality changes, psychiatric disorders including steroid psychoses or aggravation of preexisting psychiatric conditions, restlessness, schizophrenia, verbal memory loss, vertigo, withdrawn behavior Ophthalmic blurred vision, cataracts, central serous chorioretinopathy, establishment of secondary bacterial, fungal and viral infections, exophthalmos, glaucoma, increased intraocular pressure, optic nerve damage, papilledema Other abnormal fat deposits, aggravation/masking of infections, decreased resistance to infection, hiccups, immunosuppression, increased or decreased motility and number of spermatozoa, malaise, moon face, pyrexia

The side effects of prednisone include a wide range of potential adverse reactions, such as:

• Allergic reactions: anaphylactoid or hypersensitivity reactions, anaphylaxis, angioedema
• Cardiovascular effects: bradycardia, cardiac arrest, cardiac arrhythmias, cardiac enlargement, circulatory collapse, congestive heart failure
• Dermatologic effects: acne, acneiform eruptions, allergic dermatitis, alopecia, angioedema
• Endocrine effects: amenorrhea, postmenopausal bleeding or other menstrual irregularities, decreased carbohydrate and glucose tolerance
• Gastrointestinal effects: abdominal distention, abdominal pain, anorexia, constipation, diarrhea
• Hematologic effects: anemia, neutropenia
• Musculoskeletal effects: arthralgias, aseptic necrosis of femoral and humeral heads, increase risk of fracture
• Neurologic effects: convulsions, delirium, dementia, depression, dizziness
• Ophthalmic effects: blurred vision, cataracts, central serous chorioretinopathy
• Other effects: abnormal fat deposits, aggravation/masking of infections, decreased resistance to infection, hiccups, immunosuppression 2, 2

From the Research

Side Effects of Prednisone

• Osteoporosis: Prednisone has been associated with a higher risk of osteoporosis, particularly in patients with primary adrenal insufficiency 3, 4.
• Bone Mineral Density (BMD): Studies have shown that prednisone can lead to lower BMD compared to hydrocortisone, especially in the femoral neck, trochanter, and total hip 3.
• Mortality Risk: Prednisolone has been linked to a higher mortality risk in patients with primary adrenal insufficiency compared to hydrocortisone 5.
• Metabolic Comorbidities: Conventional replacement steroid therapy, including prednisone, can increase the frequency of metabolic comorbidities due to daily overexposure 6.
• Calcium-Phosphate Metabolism: Glucocorticoid replacement therapy, including prednisone, can affect calcium-phosphate metabolism and bone turnover markers 7.

Factors Influencing Side Effects

• Dose and Duration: Higher doses and longer durations of prednisone therapy may increase the risk of side effects such as osteoporosis and metabolic comorbidities 4, 7.
• Patient Characteristics: Patients with comorbid risk factors, such as autoimmune diseases or malignancies, may be more susceptible to the side effects of prednisone 5.
• Replacement Therapy: The type of replacement therapy used, such as hydrocortisone or prednisolone, can impact the risk of side effects 3, 5.