What are the contraindications for oral prednisone (corticosteroid)?

Oral Prednisone Contraindications

Oral prednisone has only two absolute contraindications according to the FDA label: systemic fungal infections and known hypersensitivity to components. 1

Absolute Contraindications

• Systemic fungal infections - Corticosteroids may exacerbate systemic fungal infections and should be avoided unless needed to control drug reactions 1
• Known hypersensitivity to prednisone or its components 1

Relative Contraindications (Use with Extreme Caution)

While not absolute contraindications, the following conditions require careful risk-benefit assessment and may preclude prednisone use in certain clinical contexts:

Infectious Disease Concerns

• Active tuberculosis or latent TB without chemoprophylaxis - Reactivation of tuberculosis may occur; patients with latent TB should receive chemoprophylaxis during prolonged therapy 1
• Varicella or measles exposure in non-immune patients - These infections can have serious or fatal courses in corticosteroid-treated patients; prophylaxis with immune globulin may be indicated 1
• Hepatitis B carriers - Virus reactivation can occur with immunosuppressive doses; screen patients before initiating prolonged treatment and consider antiviral therapy 1
• Active or latent amebiasis - Corticosteroids may activate latent amebiasis; rule out before initiating therapy in patients with tropical exposure or unexplained diarrhea 1
• Strongyloides (threadworm) infestation - Use with great care as immunosuppression may lead to hyperinfection and potentially fatal gram-negative septicemia 1
• Cerebral malaria - Avoid corticosteroids in these patients 1

Metabolic and Cardiovascular Conditions

• Uncontrolled diabetes mellitus - Listed as a relative contraindication in autoimmune encephalitis guidelines; corticosteroids induce glucose intolerance and hyperglycemia 2, 3
• Uncontrolled hypertension - Identified as a relative contraindication requiring consideration before prescribing 2, 3
• Severe cardiovascular disease - Long-term use at doses ≥7.5 mg daily increases cardiovascular risk including coronary artery disease and atrial fibrillation 4

Gastrointestinal Conditions

• Acute peptic ulcer disease - Listed as a relative contraindication in guidelines, though meta-analysis shows peptic ulcer is actually a rare complication (0.4% vs 0.3% placebo) and should not be considered an absolute contraindication 2, 5

Ophthalmologic Conditions

• Active ocular herpes simplex - Corticosteroids should not be used due to possible corneal perforation 1
• Optic neuritis - Use is not recommended and may increase risk of new episodes 1

Psychiatric Conditions

• Severe behavioral symptoms that worsen with corticosteroid therapy - Identified as a relative contraindication in autoimmune encephalitis treatment algorithms 2
• Severe psychiatric disorders - Corticosteroids can cause psychosis, mood disturbances, and emotional instability 2, 6

Other Conditions Requiring Caution

• Severe osteoporosis - Listed as a relative contraindication; long-term use increases fracture risk 2
• Immunosuppressive state requiring live vaccines - Administration of live or live-attenuated vaccines is contraindicated in patients receiving immunosuppressive doses 1

Clinical Context Matters

The decision to use prednisone despite relative contraindications depends on the severity of the underlying condition being treated. For example:

• In autoimmune encephalitis with severe presentations (NMDAR-IgG, NORSE, dysautonomia), intravenous methylprednisolone may still be indicated despite relative contraindications, with alternative agents considered when contraindications are absolute 2
• For conditions like focal segmental glomerulosclerosis or minimal change disease with relative contraindications to high-dose corticosteroids (uncontrolled diabetes, psychiatric conditions, severe osteoporosis), alternative immunosuppressive agents like cyclophosphamide or calcineurin inhibitors should be considered 2

Key Pitfalls to Avoid

• Do not prescribe corticosteroids empirically for dysphonia prior to laryngeal visualization - No evidence supports efficacy and potential for significant harm exists 2
• Screen for hepatitis B before prolonged immunosuppressive therapy - Reactivation can occur even in patients with apparently resolved infection 1
• Assess tuberculosis status before initiating therapy - Latent TB can reactivate during treatment 1
• Consider comorbid conditions including infections, diabetes, hypertension, peptic ulcer disease, and osteoporosis when prescribing, particularly for courses longer than short-term bursts 3