Judy J. Davis, M.D., F.A.A.P.
7405 N. Fresno Street
Fresno, CA 93720
(559)438-8400 Fax(559)438-1174
PREDNISONE
WHAT IS PREDNISONE?
Prednisone is one of the most universally prescribed immunosuppressant drugs. It is used mainly to treat
"autoimmune diseases" such as rheumatoid arthritis, systemic lupus erythematosus, polymyositis, inflammatory
bowel disease (ulcerative colitis and Crohn's disease) and also to prevent rejection after organ transplantation;
Prednisone is a synthetic steroid hormone. The body manufactures natural steroid hormones to control numerous
bodily functions such as metabolism, sexual function, development and blood pressure. Prednisone has similar
effects to the natural steroid called cortisol, which is made in the adrenal gland (adrenal glands are about the size of
a golf ball and are located just above the top of each kidney), Normally the body makes about 25 mg. of cortisol per
day. When the body is "stressed", it can make over 100 mg. of cortisol. Stress in this sense means trauma such as
major surgery, broken bones or any major illness. Prednisone has roughly five times the potency of cortisol, so 5 mg.
of prednisone is like 25 mg. of cortisol.
HOW DOES PREDNISONE WORK?
Prednisone seems to work by doing many things to the immune cells that are responsible for fighting infection and
identifying any foreign material that shouldn't be in the body and trying to get rid of it. Prednisone inhibits immune
cells that kill other cells; it inhibits the secretion of substances (cytokines) which tend to “rev up" the immune
system. The result is that all inflammatory processes are slowed and weakened. Inflammation is how the body kills
what it perceives as foreign. A bacterium is foreign so the body kills it with inflammation. An organ transplant is
foreign so the body tries to kill it with inflammation as well. In autoimmune diseases, the body perceives an organ as
foreign and therefore that organ becomes inflamed secondary to the body's own immune system. By turning down
the body's ability to produce inflammation, prednisone helps treat autoirnmune diseases as well as decrease the
chance of organ rejection, but unfortunately this leaves the body more susceptible to infection by bacteria, protozoa,
fungi or viruses.
HOW IS PREDNISONE GIVEN?
There are many different forms of corticosteroid preparations including Medrol (prednisolone) and Solu-Medrol
(methylprednisolone) which are both IV preparations of corticosteroid whereas prednisone is an oral preparation.
Typically prednisone or related medications are given at high doses in the beginning and then tapered down as
quickly as possible as soon as the inflammatory response or rejection is under control. These medications have
significant side effects therefore the goal of therapy is to use as low a dose as possible, to control the symptoms and
at the same time decrease the risk of side effects.
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SIDE EFFECTS OF PREDNISONE:
Ulcers and abdominal pain: Prednisone is thought to be associated with ulcers in the stomach and the first portion
of the intestine (duodenum). Also some patients taking prednisone will have "heartburn" symptoms from the
stomach area. For these reasons, some physicians commonly prescribe drugs that reduce acid in the stomach
(antacids) to be taken along with prednisone. Examples of drugs that can reduce stomach acid are Tagamet, Zantac,
Pepcid, Prilosec, Prevacid, Aciphex, Nexium, Zegerid, Kapidex and Protonix.
High blood pressure: The likelihood of developing high blood pressure while taking prednisone depends on the
dose and duration of treatment. Prednisone can cause high blood pressure in normal adults and children. The first
step in treatment is to restrict dietary salt and sometimes this is all that is needed. In other cases, a blood pressure
medication or diuretic may be required, Children tolerate these medications quite well and they are quite safe with
proper monitoring.
Weight gain: Some children will gain excessive weight while taking prednisone despite efforts to control their
diets. Mostly we give common sense advice for controlling weight: Limit in-between meal snacks, and avoid high
calorie foods, especially fats (chips, fries and other snack foods). Probably the most important thing for parents to do
is strongly encourage daily exercise.
Acne: Acne is related to the sex hormone testosterone-like effect of prednisone. If the acne is severe, patients are
sent to a dermatologist for topical treatment.
Cataracts (clouded lenses in the eyes): Cataracts are an uncommon problem in children, but about 1 % of
children on prednisone will get them. It is possible to detect the development of cataracts early in some cases and
alter the prednisone dosage to prevent worsening. Ophthalmologists say that sight is rarely altered in the long-term.
Cataracts are common in older adults whether they take prednisone or not. Cataracts that do affect vision are treated
by surgery.
Difficulty sleeping: Insomnia, night sweats and nightmares are not usually a big problem on low dose prednisone,
but can be a problem if the dose is high. Once again daily exercise is extremely helpful with this problem.
Brittle, easily broken bones: Prednisone does have a tendency to cause bones to become thinner and easier to
break than normal, however broken bones are not usually a major problem in children on prednisone. Exercise has
been shown to strengthen the bones and should be strongly encouraged. Extra calcium is prescribed while your child
is on prednisone to decrease the risk of thin bones. Another major bone problem we worry about with prednisone is
"avascular necrosis of the joint" (usually the hip). This is most often seen by high dose steroids, but can occur in
anyone on steroids even for a short period of time. This is a condition where the bone dies for unknown reason.
Although it is most common in the femur (thighbone), it can also happen in the knees and arms. The usual symptom
is pain and the diagnosis is made by x-ray. Symptoms can appear before the diagnosis can be made on x-ray, and
sometimes there are little or no symptoms. Treatment may include adjustment of the prednisone dosage, pain
management and sometimes joint replacement.
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High blood sugar and a tendency to develop diabetes: Prednisone changes the way our bodies metabolize fat and
carbohydrates (sugar and starch). This alteration results in the tendency to gain weight and the tendency to develop
abnormally high blood sugar. Normally when we eat, our blood sugar rises as carbohydrates are absorbed in the gut.
The body responds by secreting insulin, which lowers the blood sugar back to the resting level. Prednisone can make
one's body somewhat resistant to the effects of insulin, thus resulting in higher than normal blood sugar. This same
problem (insulin resistance) is what causes "adult-onset diabetes", the disease of high blood sugar. Adult-onset
diabetes can occur in adults even if they are not on prednisone, especially if they are very overweight. If this
happens, it may be necessary to take insulin shots although diabetes will occur in about 10-20% of adults taking
prednisone, it is very uncommon in young children.
Excess hair growth: Hypertrichosis or excess hair growth, can be caused by prednisone, but is usually seen with
long term use of high doses. Hypertrichosis due to prednisone is caused by the sex steroid effect that high doses of
corticosteroids can have, called an androgen effect. The androgen effect is variable, but it generally goes away when
the dose is lowered.
Muscular weakness: There are reports of fatigue and weakness due to prednisone. Again, usually these problems
are seen in high, long-term dosages. Regular exercise is an important defense against muscle weakness and fatigue.
Mood/personality swings: This is a very common side effect of prednisone. When prednisone patients feel down,
they are really blue; when they are happy, they are bouncing off the ceiling with joy. This side effect is definitely
related to dose and tends not to be apparent on the lower dosages. Outright psychosis is uncommon, but it can
happen. Psychosis is a delusional state where the patient perceives things that are not there. They may have
suspicions or beliefs that are unfounded and untrue. They may not recognize friends or family and may hear voices
and have hallucinations. Psychosis usually only happens with high doses of prednisone. Extremely vivid dreams and
nightmares are much common and can be terrifying.
Striae: Striae or stretch marks as they are commonly called can occur on high dose, long-term steroid therapy.
Unfortunately these do not resolve once prednisone therapy has been discontinued. Fortunately they are uncommon.
Poor Growth: The problem with growth is that it is so variable. Growth rates are variable, growth problems are
variable and the effects of prednisone on growth are variable. Some children grow well despite prednisone and some
do not. Generally children who are not growing as fast as they should, will return to a normal growth rate when the
prednisone is discontinued and sometimes they will catch up to where they should be. However, sometimes they will
remain smaller than they should be and never catch up. Children, who require long-term prednisone and are not
growing, should see a specialist in endocrinology (the study of hormones).
THE DANGER OF STOPPING PREDNISONE ABRUPTLY:
The adrenal gland, which makes the natural steroid hormones for the body, is suppressed by long-term prednisone
therapy. Due to adrenal inactivity, it may atrophy (shrink). Since some steroid hormones are necessary for life,
abruptly stopping prednisone may leave one without any steroids at all; a life threatening condition called
Addisonian crisis can occur. The symptoms of this are low blood pressure, nausea, vomiting, severe weakness and
death can occur. Given time, if the adrenal gland is stimulated to produce steroids by GRADUALLY reducing the
dosage of prednisone, it will begin to wake up and produce natural steroids in most cases. During the weaning of
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prednisone, if one becomes ill, more steroids are needed since the natural response to stress such as trauma, an
operation or infection is for the adrenal gland to pour out steroids. Until one's adrenal gland is geared up, it will not
be possible to pour out more steroids. Anyone on steroids, or recently weaned off steroids, needs to be aware of this
and additional steroids need to be given during a concurrent illness. Many patients will experience fatigue; joint pain
and muscle aches during the time they are weaning from prednisone and this may represent a deficiency of steroids.
The symptoms usually go away after a few weeks or if prednisone is resumed. Rarely significant behavioral changes
and mood swings are noted during prednisone weaning which requires a very slow tapering of prednisone therapy in
order to minimize the significant, unpleasant, behavioral changes.
SUMMARY:
Most children benefit considerably from prednisone therapy when it is used to treat various disorders. However,
because of the significant side effects of prednisone, which are highly variable from person to person, the shortest
course of prednisone therapy is the ultimate goal so as to avoid significant side effects.
Judy J. Davis, M.D., F.A.A.P.
Fellow American Academy of Pediatrics
Fellow Sub-Board American Academy of Pediatric Gastroenterology
American Board of Nutrition
Clinical Professor, Department of Pediatrics, University of California, San Francisco
REVISED 11/09