Prednisone Side Effects And Warnings

Learn Facts and Information About Prednisone, Both Side Effects and Benefits

Prednisone Withdrawal Symptoms

Prednisone Withdrawal Symptoms

Prednisone is an anti-inflammatory drug that is classified as a glucocorticosteroid - a class of endogenous hormones that are produced by the adrenal gland in the human body. Glucocorticosteroids (or glucocorticoids) are stress hormones that aim to prepare the body to respond to infections, diseases and other stressful events like surgery, accidents and even pain caused by the withdrawal of certain medications[1] etc.

Prednisone is a synthetic form of glucocorticoid that is mainly prescribed for therapeutic reasons to minimize the intensity of inflammatory or autoimmune reactions in the body and is not generally considered a drug of abuse. However, surprisingly, abrupt cessation of therapy is associated with moderate to severe withdrawal symptoms.

Classic Withdrawal Symptoms Frequently Reported After Cessation of Prednisone

The intensity or severity of symptoms is dependent on the duration of therapy, underlying medical conditions and dosage frequency of prednisone. Withdrawal symptoms can include:

  • Non-specific symptoms that are generally missed or dismissed by most individuals, such as severe fatigue, weakness, fever, substantial and unplanned weight loss.
  • Gastrointestinal upset marked by decreased appetite, nausea, vomiting, diarrhea (that is often severe and result in fluid and electrolyte imbalance with vomiting) and abdominal pain. Sometimes life-threatening complications can ensue, such as ileus.
  • Autonomic changes due to loss of endogenous glucocorticoid influence, like low blood pressure which is associated with dizziness or even fainting.
  • Changes in blood sugar concentration that is especially pronounced in diabetics.
  • Changes in normal menstrual cycles and impaired fertility.
  • Impaired quality of life by vague involvement of multiple systems like joint pain (also known as arthralgia), muscle aches, mental changes, or changes in the serum concentration of calcium.

In some susceptible patients, abrupt prednisone withdrawal may also lead to severe complications like acute adrenal crisis, which is a life-threatening condition that is marked by high grade fever, excessive sweating, changes in the complexion of skin, low blood pressure, dehydration, abdominal pain, flank pain, joint pain, changes in heart rate, rigors and shaking chills - ultimately culminating in confusion, delirium and coma or even death.

What is the Pathophysiology of Prednisone Withdrawal Symptoms?

The human body is very sensitive and calculated when it comes to the maintenance of its internal environment, so in situations where we consume glucocorticoids from external sources (like prednisone), the human adrenal glands shut down the production of glucocorticoids. This creates a deficit in internal production, but as long as you are getting prednisone from external sources, no complications or adverse effects are observed. However, in case of abrupt cessation[2], the human body retaliates to low glucocorticoids by:

  • Increasing the susceptibility of developing infections.
  • Creating immune dysfunctions in the body.
  • Reversing the symptoms for which you initiated the therapy.
  • Causing depression or severe mood changes.

Healthcare providers therefore usually prescribe prednisone for limited periods of time and taper the dosage as soon as the acute symptoms are well under control.

Clinical studies indicate that well-executed withdrawal of prednisone decreases the requirement of insulin and antihypertensive drugs for the control of blood pressure and a better serum lipid profile[3].

What is the Dosage/Duration At Which Withdrawal Symptoms May Occur?

With prolonged intake, individuals may develop Cushing's syndrome, marked by changes in the redistribution of body fat (leading to buffalo hump, moon face, appearance of abdominal striae), high risk of infections, acne and other skin lesions, osteoporosis (and higher risk of pathological fractures), changes in blood lipid levels and diabetes. Cushing's syndrome generally marks the onset of full-blown physical glucocorticoid dependence. If you are experiencing one or more symptoms of Cushing's syndrome, abrupt cessation may increase the risk of complications. A case study[2] suggested that people with tuberculosis, asthma and other pulmonary conditions can develop Cushing syndrome within 6 months with a dosage of 30 mg/day.

Many patients make inquiries to their healthcare providers regarding the optimal and safe duration of therapy, during which the risk of physical dependence is minimal. Although there is no definite period, the chances of dependence are fairly high with a dosage higher than 7.5 mg/day for more than 3-4 weeks.

What is the Ideal Tapering Regimen?

Obviously, your healthcare provider is the best person to guide you about the tapering protocols of prednisone depending upon your health status and duration of therapy. Traditionally, as a guideline, these tapering protocols are used in most clinical settings:

  • For a dosage more than 40 mg/day, a decrement of 5 mg at a time for a few days
  • A decrement of 2.5 mg/day if the dosage reaches 20 mg/day.
  • Decrease the dosage by 1 mg once the dosage reaches 10 mg/day.

Once again, this is not the absolute rule and the tapering protocols vary from person to person depending upon the response of their adrenal glands and other tissues.

References:

  1. Pageler, L., Katsarava, Z., Diener, H. C., & Limmroth, V. (2008). Prednisone vs. placebo in withdrawal therapy following medication overuse headache. Cephalalgia, 28(2), 152-156.
  2. AMATRUDA, T. T., HOLLINGSWORTH, D. R., D'ESOPO, N. D., UPTON, G. V., & BONDY, P. K. (1960). A study of the mechanism of the steroid withdrawal syndrome. Evidence for integrity of the hypothalamicpituitary-adrenal system. Journal of Clinical Endocrinology & Metabolism, 20(3), 339-354.
  3. Stegall, M. D., Everson, G. T., Schroter, G., Karrer, F., Bilir, B., Sternberg, T., ... & Kam, I. (1997). Prednisone withdrawal late after adult liver transplantation reduces diabetes, hypertension, and hypercholesterolemia without causing graft loss. Hepatology, 25(1), 173-177.

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