What are the absolute and relative contraindications to initiating prednisone therapy?

Contraindications to Prednisone Before Starting

The only absolute contraindication to prednisone is systemic fungal infection and known hypersensitivity to the drug or its components. 1

Absolute Contraindications

• Systemic fungal infections: Prednisone is absolutely contraindicated in patients with active systemic fungal infections due to immunosuppressive effects that can worsen the infection 1

• Known hypersensitivity: Documented allergy to prednisone or any component of the formulation is an absolute contraindication 1

  • True allergic reactions to corticosteroids are rare but can manifest as anaphylaxis (60.8% of reported cases), urticaria/angioedema (26.7%), or other immediate hypersensitivity reactions 2
  • Cross-reactivity between different corticosteroids is possible, and intradermal skin testing can help identify safe alternatives if hypersensitivity is suspected 2, 3, 4

Relative Contraindications and High-Risk Situations Requiring Extreme Caution

While not absolute contraindications, the following conditions require careful risk-benefit assessment before initiating prednisone:

Gastrointestinal Conditions

• Active or latent peptic ulcers: Steroids increase risk of perforation, and signs of peritoneal irritation may be minimal or absent in patients on corticosteroids 1
• Diverticulitis: Increased perforation risk 1
• Fresh intestinal anastomoses: Risk of anastomotic breakdown 1
• Nonspecific ulcerative colitis: Increased perforation risk 1

Cardiovascular and Renal

• Congestive heart failure: Sodium retention with resultant edema can worsen heart failure 1
• Hypertension: Corticosteroids should be used with caution due to sodium retention 1
• Renal insufficiency: Potassium loss and fluid retention require careful monitoring 1

Infectious Disease Considerations

• Active infections (other than systemic fungal): While not an absolute contraindication, requires concurrent antimicrobial therapy and close monitoring
• Recent exposure to chickenpox or measles: Patients should be warned to avoid exposure and seek immediate medical advice if exposed 1

Endocrine and Metabolic

• Hypothyroidism: Enhanced effect of corticosteroids in these patients 1
• Diabetes mellitus: Corticosteroids worsen glycemic control (though this is manageable with dose adjustments)

Musculoskeletal

• Osteoporosis or high fracture risk: Corticosteroids decrease bone formation and increase bone resorption 1
  • Postmenopausal women require special consideration before initiating therapy 1
  • Prophylactic measures (calcium, vitamin D, bisphosphonates) should be initiated if prednisone ≥5 mg daily for ≥3 months is anticipated 5, 1

Neuromuscular

• Myasthenia gravis: Risk of acute myopathy with high-dose corticosteroids, particularly when combined with neuromuscular blocking drugs 1
• Disorders of neuromuscular transmission: Increased risk of generalized myopathy that may involve ocular and respiratory muscles 1

Psychiatric

• Existing emotional instability or psychotic tendencies: May be aggravated by corticosteroids 1
• History of severe psychiatric reactions to steroids: Derangements can range from euphoria and insomnia to severe depression and frank psychotic manifestations 1

Ophthalmologic

• Glaucoma or elevated intraocular pressure: Intraocular pressure may become elevated; if therapy continues >6 weeks, pressure should be monitored 1

Hepatic

• Cirrhosis: Enhanced corticosteroid effect due to decreased metabolism 1

Critical Pre-Treatment Considerations

Before initiating prednisone, ensure:

1. Rule out systemic fungal infection through appropriate testing if clinically suspected 1

2. Document any prior corticosteroid hypersensitivity reactions and consider skin testing if history is unclear 2, 3, 4

3. Assess fracture risk in patients requiring prolonged therapy (≥3 months) and initiate bone protection measures proactively 5, 1

4. Plan for gastroprotection with proton pump inhibitors for patients with GI risk factors or receiving moderate-to-high doses 5, 6

5. Consider PCP prophylaxis if prednisone ≥20 mg for ≥4 weeks is anticipated 7

6. Counsel patients about not discontinuing abruptly, avoiding exposure to chickenpox/measles, and seeking immediate care for fever or signs of infection 1

Important Clinical Pitfall

The most common error is not recognizing that there are very few true absolute contraindications to prednisone. The risk-benefit calculation often favors treatment even in high-risk situations, provided appropriate monitoring and prophylactic measures are implemented. The key is not whether to use prednisone, but rather how to use it safely with appropriate precautions and monitoring in place.