Prednisone for Osteoarthritis: Not Recommended
Prednisone 20mg daily for osteoarthritis is not appropriate and should be discontinued. Oral corticosteroids have no established role in the treatment of osteoarthritis, and this patient is at increased risk for perioperative complications given the upcoming knee surgery 1.
Why Prednisone Should Not Be Used for Osteoarthritis
Lack of Evidence for Efficacy
Oral prednisone has not been shown to be effective for osteoarthritis. A randomized controlled trial in dogs with osteoarthritis found that low-dose prednisone (0.1 mg/kg/day, equivalent to approximately 7mg daily in humans) did not reduce osteophyte size, cartilage ulceration, synovial inflammation, or improve any measure of disease severity 2.
While a 2019 trial showed short-term benefit of 10mg prednisolone for hand osteoarthritis with documented synovial inflammation, this was specifically for inflammatory flares in hand joints, not for routine osteoarthritis management or knee osteoarthritis 3.
Intra-articular corticosteroid injections (not oral prednisone) have demonstrated short-term efficacy for knee osteoarthritis pain relief lasting 1-3 weeks, but oral systemic corticosteroids are not recommended 4, 5.
Significant Perioperative Risks
This patient is awaiting knee surgery, which creates additional concerns:
Patients taking ≥15-20 mg/day prednisone have significantly elevated infection risk following total joint arthroplasty, with an odds ratio of 1.68 for postoperative infectious complications 6.
At 20mg daily, this patient exceeds the CDC's immunosuppression threshold of 20mg/day for ≥2 weeks 1, 6.
Optimal candidates for elective total knee arthroplasty should be on <20mg/day prednisone when possible 1.
Recent data shows that even short-term postoperative prednisone use is associated with increased risk of manipulation under anesthesia (OR 1.23), lysis of adhesions (OR 1.58), acute kidney injury (OR 1.47), and pneumonia (OR 4.04) 7.
Recommended Management Algorithm
Immediate Action
Discontinue prednisone 20mg daily - this medication provides no benefit for osteoarthritis and increases surgical risk 1, 6, 2.
Taper appropriately - if the patient has been on 20mg daily for >2 weeks, taper gradually (e.g., reduce by 5mg every 3-5 days) to avoid adrenal insufficiency 8.
Alternative Pain Management for Osteoarthritis
Replace prednisone with evidence-based osteoarthritis treatments:
Continue Celebrex (celecoxib) - NSAIDs are conditionally recommended for osteoarthritis pain 9.
Consider tramadol if additional analgesia needed while awaiting surgery 9.
Intra-articular corticosteroid injection may provide 1-3 weeks of pain relief if needed to bridge to surgery 4, 5.
Physical therapy is not mandatory to delay surgery but may help with preoperative conditioning 1.
Perioperative Glucocorticoid Management (If Patient Had Been on Appropriate Dose)
For context, if this patient had a legitimate indication for glucocorticoids (e.g., rheumatoid arthritis, polymyalgia rheumatica):
Patients on ≤16mg/day prednisone should continue their usual daily dose perioperatively rather than receiving stress-dose steroids 1, 8.
No need to check morning cortisol levels - this would not change management 8.
Resume usual dose immediately postoperatively once oral intake possible 1, 8.
Critical Pitfalls to Avoid
Do not continue prednisone simply because the patient reports it helps with pain - this likely represents a placebo effect or general anti-inflammatory properties, not disease-modifying benefit for osteoarthritis 2.
Do not delay surgery to taper steroids if the patient can be tapered off within 2-4 weeks - proceed with discontinuation and schedule surgery once off prednisone 1, 6.
Do not substitute with stress-dose steroids perioperatively - this patient has no indication for glucocorticoids and adding them would only increase infection risk 8, 6.
Medication Refill Decision
Refill all medications EXCEPT prednisone:
- Provide the other medications (nortriptyline, metformin, statin, perindopril, Jardiance, NovoMix insulin, Celebrex, zopiclone, Zostrix cream) as requested 9.
- Explain that prednisone is not appropriate for osteoarthritis and increases surgical complications 1, 6, 2.
- Offer alternative pain management strategies as outlined above 9, 4.
- Coordinate with the patient's usual provider for ongoing management and surgical optimization 1.