Prednisone


Article Author:
Yana Puckett


Article Editor:
Abdullah Bokhari


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Mitchell Farrell
Brian Froelke


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James Hughes
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Nazia Sadiq
Hajira Basit
Phillip Hynes
Tehmina Warsi


Updated:
4/2/2019 4:38:58 PM

Indications

Prednisone is a synthetic, anti-inflammatory glucocorticoid that derives from cortisone. It is biologically inert and converted to prednisolone in the liver. Prednisone is an FDA-approved, delayed-release corticosteroid indicated as an anti-inflammatory or immunosuppressive agent to treat a broad range of diseases including immunosuppressive/endocrine, rheumatic, collagen, dermatologic, allergic states, ophthalmic, respiratory, hematologic, neoplastic, edematous, gastrointestinal (GI, acute exacerbations of multiple sclerosis, and as an anti-inflammatory and an antineoplastic agent. Prednisone is a corticosteroid (cortisone-like medicine or steroid). It works on the immune system to help relieve swelling, redness, itching, and allergic reactions. This medicine is available only with a doctor's prescription.[1]

It is common for prednisone to be prescribed for other indications or in a different dosage than shown in the label information. These are called off-label prescribing or non-FDA-approved indications. Other countries may mention "approved" or "licensed" indications that do not apply in the United States.[2]

Mechanism of Action

Prednisone decreases inflammation by suppressing the migration of polymorphonuclear leukocytes and reversing increased capillary permeability. It also suppresses the immune system by reducing the activity and the volume of the immune system. The antineoplastic effects may be related to the inhibition of glucose transport, phosphorylation, or induction of cell death in immature lymphocytes. It may have antiemetic effects by blocking the cerebral innervation of the emetic center via inhibition of prostaglandin.

Prednisone is a prodrug to prednisolone, which mediates its glucocorticoid effects. Prednisone is a synthetic glucocorticoid that has both anti-inflammatory and immunomodulating properties. 

After cell surface receptor attachment and entry into the cell, prednisone enters the nucleus where it binds and activates specific nuclear receptors, which result in altered gene expression and inhibition of proinflammatory cytokine production. This agent decreases the number of circulating lymphocytes, inducing cell differentiation, and stimulates apoptosis in sensitive tumor cell populations.

The effects of glucocorticoids are mediated by mechanisms that alter DNA replication within the nucleus.

Administration

Prednisone may be administered orally with food or milk to decrease gastrointestinal upset. The maximal activity of the adrenal cortex is between 2 am, and 8 am, and it is minimal between 4 pm and midnight. Exogenous corticosteroids suppress adrenocorticoid activity the least when given at the time of maximal activity (am) for single dose administration. Therefore, it is recommended that Prednisone be administered in the morning prior to 9 am and when large doses are given, administration of antacids between meals to help prevent peptic ulcers. Multiple dose therapy should be evenly distributed in evenly spaced intervals throughout the day. Antacids also may be administered between meals to help prevent peptic ulcers.[3]

The delayed-release tablets should be swallowed whole without breaking, dividing, crushing, or chewing. The oral solution should be administered with the provided calibrated dropper only. Other forms of steroids may be available if the oral form is not well-tolerated, for example, intramuscularly (IM), subcutaneously (SQ). Depending on the disease process, topical steroids may also be utilized. It is best to take this medicine with food. Swallow the medication whole. Store the medicine in a tightly-closed container at room temperature, away from heat, moisture, and direct light. Do not freeze the oral liquid. Other routes of administration include liquid, solution, syrup, tablet, delayed-release tablets, nasal, rectal, injection, and intravenous.

As a patient if they are taking the following medications: aminoglutethimide, amphotericin B, carbamazepine, cholestyramine, cyclosporine, digoxin, isoniazid, ketoconazole, phenobarbital, phenytoin, or rifampin, a blood thinner (such as warfarin), NSAID pain or arthritis medicine (such as aspirin, diclofenac, ibuprofen, naproxen celecoxib), diuretic (water pill), diabetes medicine, a macrolide antibiotic (such as azithromycin, clarithromycin, erythromycin), estrogen (including birth control pills or hormone replacement therapy).

Adverse Effects

The primary adverse effects of prednisone include hyperglycemia, insomnia, increased appetite, hypertension, osteoporosis, edema, adrenal suppression, cataracts, and delayed wound healing.

Adverse effects are common in patients receiving glucocorticoids in high doses or over a long period. Potential adverse effects include skin fragility, weight gain, increased risk of infections, and fractures. Important cardiovascular and metabolic effects are hypertension, hyperglycemia, and dyslipidemia.[4]

Other adverse reactions include adrenal insufficiency, particularly when undergoing stressful procedures or during sepsis. This can typically be diagnosed when the patient is hypotensive and not responsive to fluids, vasopressors, or cardiogenic medications. Once suspicion of adrenal insufficiency exists, treatment should be administered right away with a dose of 100 mg of hydrocortisone every eight hours. 

Contraindications

Prednisone is contraindicated in patients with documented hypersensitivity to the drug or components of the formulation. The administration of live or live-attenuated vaccines is also contraindicated when immunosuppressive doses are administered. The administration of prednisone in the presence of systemic fungal infections is also contraindicated.[5]

Monitoring

It is important to monitor for allergic reaction (itching or hives, swelling in your face or hands, swelling or tingling in your mouth or throat, chest tightness, trouble breathing), dark freckles, skin color changes, coldness, weakness, tiredness, nausea, vomiting, weight loss, rapid weight gain, depression, unusual thoughts, feelings, or behaviors, trouble sleeping, fever, chills, cough, sore throat, and body aches, muscle pain or weakness, swelling in your hands, ankles, or feet, severe stomach pain, red or black stools, skin changes or growths, trouble seeing, eye pain, or headache.

It is important to monitor patients with giant cell arteritis because increased cumulative glucocorticoid exposure was associated with an increased risk of glucocorticoid-related adverse effects.[6]

Doctors can opt to monitor serum glucose, blood pressure, electrolytes, weight, bone mineral density, hemoglobin, occult blood loss, growth in pediatric patients, and infections. The HPA axis suppression should also be assessed by morning cortisol test, adrenocorticotropic hormone stimulation test, and by measuring urinary free cortisol test.

When monitoring, it is important to remember the elimination half-life of prednisone is 3 to 4 hours in adults and 1 to 2 hours in children.

More common symptoms to monitor are aggression, agitation, blurred vision, a decrease in the amount of urine, dizziness, irregular heartbeat or pulse, headache, irritability, mood changes, irregular breathing, numbness or tingling in the arms or legs, pounding in the ears, shortness of breath, swelling of the fingers, hands, feet, or lower legs, trouble thinking, speaking, or walking, troubled breathing at rest, or weight gain.

Toxicity

Like any anti-inflammatory agent, steroid toxicity is treated similarly to any non-steroidal anti-inflammatory drugs overdose or toxicity. Although the frequency of life-threatening complications from steroids and NSAID overdose is low, the overdose response ranges from no symptoms to death despite intensive-care treatment. Most symptoms are an excess of the pharmacological action of steroids and NSAIDs and include abdominal pain, nausea, vomiting, drowsiness, dizziness, headache, ear ringing, and nystagmus. A significant dose-response relationship was found between the long-term use of systemic corticosteroids and the development of systemic corticosteroid-related complications in patients with severe asthma, resulting in an increased burden and costs on the health care system.[7]

Enhancing Healthcare Team Outcomes

Managing drug adverse effects requires an interprofessional team of healthcare professionals that includes a nurse, laboratory technologists, pharmacist and a number of physicians in different specialties. Without proper management, the adverse effects from prednisone overdose are high. Systemic corticosteroids are widely used to treat a variety of autoimmune and inflammatory disorders. Prolonged use, especially at high doses, can cause serious adverse effects. The most common systems involved include musculoskeletal, endocrine, cardiovascular, and central nervous system (CNS) and gastrointestinal (GI) tract. Prednisone's side effects can be minimized by monitoring the patient and putting preventative measures in place. Some of these preventative measures include using lower potency dosages and starting patients on the lowest effective dosage per guidelines. The patient needs to informed of the adverse effects so they may be educated and aware of making the proper lifestyle modifications to help reduce the risk of adverse effects. Advise patients to contact their doctor and seek medical attention if they experience any of these known adverse effects. A steroid treatment card can be recommended to show to all healthcare professionals involved in their care and management. Adults versus children monitoring and care should be noted, particularly in reference to growth curve complications, adrenal suppression, and osteoporosis.[8]


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Prednisone - Questions

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A 18 year old diabetic male patient suffers from an acute asthma attack. His doctor prescribes him prednisone 40 mg by mouth once daily for 7 to 10 days. What is a possible short-term adverse effect of prednisone after this duration of time?



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A patient is taking 100 mg of hydrocortisone IV every 8 hours and is being switched to oral prednisone. What is the equivalent dose?



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A patient is being released from the hospital after treatment for multiple sclerosis. Part of their discharge regimen is a 5-week course of steroids. Which of the following is true regarding counseling a patient about prednisone therapy?



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A 65-year-old man on long-term multi-drug therapy presents with hyperglycemia, hypertension, and decreased bone mineralization. He is also anemic. His stool tests positive for occult blood and have a 'coffee grounds' appearance. Which of the following drugs is the likely culprit in his condition?



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Which class of drug is prednisone?



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A female client has just been diagnosed with rheumatoid arthritis and is started on a course of prednisone as bridging therapy to methotrexate. What adverse effects will the nurse potentially note in this client? Select all that apply.



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A patient with rheumatoid arthritis is started on prednisone. The patient is asked to follow up closely to monitor her response to the drug and for possible adverse effects. Which of the following is a potential adverse effect of prednisone? Select all that apply.



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A 55-year old male with a history of chronic prednisone use for rheumatoid arthritis was admitted to the hospital with a severe foot infection 24 hours ago. Despite IV fluids, two vasopressor medications, and antibiotics, he remains hypotensive. What should be done next?



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Prednisone - References

References

Liu D,Ahmet A,Ward L,Krishnamoorthy P,Mandelcorn ED,Leigh R,Brown JP,Cohen A,Kim H, A practical guide to the monitoring and management of the complications of systemic corticosteroid therapy. Allergy, asthma, and clinical immunology : official journal of the Canadian Society of Allergy and Clinical Immunology. 2013 Aug 15     [PubMed]
Gale S,Wilson JC,Chia J,Trinh H,Tuckwell K,Collinson N,Dimonaco S,Jick S,Meier C,Mohan SV,Sarsour K, Risk Associated with Cumulative Oral Glucocorticoid Use in Patients with Giant Cell Arteritis in Real-World Databases from the USA and UK. Rheumatology and therapy. 2018 May 11     [PubMed]
Bunte K,Smith DJ,Chappell MJ,Hassan-Smith ZK,Tomlinson JW,Arlt W,Tiňo P, Learning pharmacokinetic models for in vivo glucocorticoid activation. Journal of theoretical biology. 2018 Oct 14     [PubMed]
Ryu RJ,Easterling TR,Caritis SN,Venkataramanan R,Umans JG,Ahmed MS,Clark S,Kantrowitz-Gordon I,Hays K,Bennett B,Honaker MT,Thummel KE,Shen DD,Hebert MF, Prednisone Pharmacokinetics During Pregnancy and Lactation. Journal of clinical pharmacology. 2018 Sep     [PubMed]
Dalal AA,Duh MS,Gozalo L,Robitaille MN,Albers F,Yancey S,Ortega H,Forshag M,Lin X,Lefebvre P, Dose-Response Relationship Between Long-Term Systemic Corticosteroid Use and Related Complications in Patients with Severe Asthma. Journal of managed care     [PubMed]
Bergmann TK,Barraclough KA,Lee KJ,Staatz CE, Clinical pharmacokinetics and pharmacodynamics of prednisolone and prednisone in solid organ transplantation. Clinical pharmacokinetics. 2012 Nov     [PubMed]
Martinez FJ,Lederer DJ, Focus on Idiopathic Pulmonary Fibrosis: Advancing Approaches to Diagnosis, Prognosis, and Treatment. Chest. 2018 Oct     [PubMed]
Puckett Y,Zhang K,Blasingame J,Lorenzana J,Parameswaran S,Brooks Md Facs SE,Baronia BC,Griswold J, Safest Time to Resume Oral Anticoagulation in Patients with Traumatic Brain Injury. Cureus. 2018 Jul 3     [PubMed]

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