What are the side effects of taking prednisone (corticosteroid)?

Side Effects of Prednisone

Prednisone causes a wide range of side effects affecting nearly every organ system, with the severity and type depending primarily on dose and duration of treatment. 1, 2

Short-Term Side Effects (First Few Weeks)

The most common early side effects include:

• Weight gain and fluid retention occur within the first few weeks of therapy and are among the most frequently reported patient concerns 1, 3
• Increased appetite leading to additional weight gain 1, 3
• Insomnia, restlessness, and nervousness affect over 30% of patients taking corticosteroids 3, 4
• Gastric irritation with increased risk of peptic ulcer formation 3, 2
• Facial rounding (moon face) can begin developing even during short-term use 1, 2
• Hypertension can develop or worsen quickly 3, 2
• Mood disturbances ranging from euphoria and hypomania to depression, anxiety, and emotional instability 1, 3, 2

Long-Term Side Effects (Beyond 6 Weeks)

Prolonged prednisone use, especially at doses >10 mg daily, is associated with serious and potentially irreversible complications that should be avoided whenever possible. 1

Musculoskeletal Complications

• Osteoporosis and increased fracture risk are among the most serious complications, with vertebral compression fractures occurring in up to 27% of patients 1, 3
• Even low doses (5 mg daily) suppress bone formation and may reduce bone repair, as demonstrated in randomized controlled trials 5
• Aseptic necrosis of femoral and humeral heads can develop even at moderate doses 1, 3, 2
• Steroid myopathy affecting diaphragmatic and intercostal muscles, along with general muscle weakness 1, 2

Metabolic and Endocrine Effects

• Hyperglycemia and worsening of diabetes are common, particularly with prednisone, requiring blood glucose monitoring 3, 2
• Redistribution of body fat with truncal obesity, moon facies, and buffalo hump occurs in 80% of patients after two years 1, 3
• Hypothalamic-pituitary-adrenal (HPA) axis suppression with potential for adrenal insufficiency after withdrawal 2
• Dyslipidemia increasing cardiovascular disease risk 3

Ophthalmologic Effects

• Posterior subcapsular cataracts develop with prolonged use 1, 3, 2
• Increased intraocular pressure and glaucoma can occur, requiring regular monitoring 1, 3, 2

Neuropsychiatric Effects

• Severe mood disturbances including depression, psychosis, delirium, and cognitive impairment (memory deficits, impaired concentration) 3, 2
• Sleep disturbances are extremely common and significantly impact quality of life 3

Dermatologic Effects

• Skin atrophy, thinning, and fragility with easy bruising (ecchymoses and petechiae) 1, 2
• Impaired wound healing 2
• Acne, hirsutism, and striae 1, 2

Infectious Complications

• Increased risk of both opportunistic and non-opportunistic infections including pneumonia, skin infections, and sepsis 3, 2
• Reactivation of latent tuberculosis in susceptible patients 2
• Hepatitis B virus reactivation in carriers 2
• Varicella and measles can have serious or fatal courses in non-immune patients 2

Cardiovascular Effects

• Hypertension or aggravation of existing hypertension 2
• Increased risk of myocardial rupture following recent myocardial infarction 2
• Thromboembolism and thrombophlebitis 2

Gastrointestinal Effects

• Peptic ulcer with possible perforation and hemorrhage 2
• Pancreatitis 2
• Perforation of small and large intestine, particularly in patients with inflammatory bowel disease 2

Dose-Dependent Risk Profile

Severe adverse effects occur mainly at doses >20 mg/day for more than 18 months, leading to treatment discontinuation in about 15% of patients. 1

• Doses >10 mg daily for prolonged periods significantly increase risk of serious complications 1
• Duration of treatment longer than 6 weeks significantly increases risk of adverse effects 3
• Up to 80% of patients experience adverse effects after two years of therapy 1

Critical Monitoring Requirements

To minimize complications, implement the following monitoring:

• Blood pressure and blood glucose monitoring should begin immediately, even during short courses 3
• Bone density testing (DEXA scan) at baseline and annually for patients on long-term therapy 1, 3
• Regular eye examinations for cataracts and glaucoma 1, 3
• Weight monitoring to detect rapid fluid retention 3
• Psychiatric evaluation between 2-4 weeks for mood instability, sleep disturbances, and psychotic symptoms 6
• Complete blood counts at least every 6 months when combined with azathioprine 1

Prevention Strategies

All patients receiving corticosteroids should receive calcium (800-1000 mg/day) and vitamin D (800 IU/day) supplementation to prevent osteoporosis. 1, 3

• Consider Pneumocystis jirovecii pneumonia prophylaxis for patients taking ≥20 mg prednisone for ≥4 weeks 3
• Update all vaccines before starting immunosuppressive therapy 3
• Avoid live vaccines in patients already taking immunosuppressants 3
• Consider steroid-sparing agents when long-term therapy is anticipated 3
• Actively taper to the lowest steroid dose needed for remission and attempt withdrawal after achieving remission 1

Special Population Considerations

Pediatric Patients

• Growth suppression is a major concern, occurring even at low systemic doses and without laboratory evidence of HPA axis suppression 2
• Growth velocity may be a more sensitive indicator of systemic corticosteroid exposure than HPA axis function tests 2
• The goal in children is to eventually become glucocorticoid-free to prevent multiple long-term complications 1

Elderly Patients

• Require more careful monitoring and often lower doses due to increased risk of complications 3
• Dose selection should be cautious, usually starting at the low end of the dosing range 2
• Increased risk of diabetes mellitus, fluid retention, and hypertension 2

Patients with Pre-existing Conditions

• Patients with diabetes, chronic liver disease, or chronic kidney disease have increased risk of complications and require close monitoring 3
• Patients with bipolar disorder or history of steroid-induced psychosis should avoid prednisone/prednisolone entirely if possible 6

Common Pitfalls to Avoid

• Underestimating the impact of sleep disturbances and mood changes on quality of life is a frequent clinical error 3
• Failing to implement bone protection measures even with low-dose therapy, as 5 mg daily can suppress bone formation 5
• Not screening for latent infections (tuberculosis, hepatitis B) before initiating therapy 2
• Abrupt discontinuation can lead to adrenal insufficiency; gradual tapering is essential 2