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Prednisone belongs to the class of glucocorticoids, hormones that regulate metabolism and immune response. After oral administration, prednisone is absorbed and converted in the liver into its active form, prednisolone. Prednisolone then penetrates cells and binds to specific cytoplasmic receptors. This complex translocates into the cell nucleus, where it modulates gene expression, suppressing the production of pro-inflammatory substances such as cytokines and prostaglandins.

Prednisone’s mode of action and physiological impact overview

As a result, prednisone exerts potent anti-inflammatory and immunosuppressive effects. It reduces the migration of leukocytes (white blood cells) to the site of inflammation and decreases capillary permeability, leading to a reduction in swelling and redness. Simultaneously, overall immune system activity is suppressed – the number of lymphocytes decreases, and their function is inhibited. In addition to its anti-inflammatory action, prednisone can suppress the abnormal growth of certain immune system cells, making it useful in the treatment of specific types of leukemia and lymphoma. Essentially, prednisone mimics the action of the natural hormone cortisol but in a more concentrated and targeted manner.

Key Medical Applications of Prednisone

Prednisone is widely used in various medical fields as a "rescue therapy" for severe inflammation and immune hyperactivity. Below are the primary conditions and diseases for which prednisone is prescribed:

Autoimmune and Rheumatic Diseases: Prednisone has significantly improved the treatment of rheumatoid arthritis, systemic lupus erythematosus, vasculitis, and dermatomyositis. It rapidly reduces inflammation in joints and tissues, alleviating pain and stiffness. Before the discovery of corticosteroids, these diseases often led to severe disability, but prednisone has allowed for better disease control.

Allergic Reactions and Asthma: In severe allergic reactions (such as angioedema) and acute asthma attacks, prednisone is life-saving by reducing airway swelling and suppressing allergic inflammation. It is also used for bronchial asthma, allergic dermatitis, and hay fever when other treatments fail.

Respiratory Diseases: In pulmonology, prednisone is used to treat exacerbations of chronic obstructive pulmonary disease (COPD), severe pneumonia with inflammatory response, sarcoidosis, and other granulomatous lung diseases. It reduces inflammatory tissue damage and improves respiratory function.

Dermatology: For severe skin conditions such as psoriasis, eczema, and bullous pemphigoid, prednisone helps reduce skin inflammation, itching, and rashes, especially when topical treatments are ineffective.

Gastroenterology: Inflammatory bowel diseases (such as Crohn’s disease and ulcerative colitis) are treated with prednisone to suppress immune activity against the intestinal lining, leading to disease remission. It is also used in autoimmune hepatitis.

Oncology and Hematology: Prednisone is included in certain chemotherapy protocols (e.g., for lymphomas and leukemias) to help destroy malignant lymphocytes. Additionally, it alleviates chemotherapy-related side effects, such as nausea, due to its antiemetic properties.

Transplant Medicine: After organ transplantation (e.g., kidney), prednisone is part of immunosuppressive therapy to prevent graft rejection. It suppresses the body's immune response against the transplanted tissue, allowing successful organ integration.

Endocrinology: In cases of acute adrenal insufficiency (Addisonian crisis) or pituitary dysfunction, prednisone can temporarily substitute for natural cortisol. However, for long-term hormone replacement therapy, more physiological alternatives (e.g., hydrocortisone) are typically preferred.

It is important to note that prednisone is usually prescribed for short-term use at the lowest effective dose. In some cases, long-term low-dose maintenance therapy is required, such as for chronic autoimmune diseases, but patients undergoing prolonged treatment require close monitoring.

Monitoring and Managing Side Effects of Prednisone Therapy

Prednisone is an extremely effective but double-edged sword—while it provides substantial benefits, it can also cause numerous side effects. Since glucocorticoids influence nearly all organs and systems, prolonged or high-dose prednisone use may lead to the following adverse effects:

Endocrine and Metabolic Disorders: Prednisone can increase blood glucose levels, leading to steroid-induced diabetes. It also stimulates appetite, often resulting in weight gain and the characteristic "Cushingoid" appearance—moon face, central obesity, and a "buffalo hump" on the back. Prolonged use may lead to Cushing’s syndrome, a hormonal imbalance similar to that caused by adrenal tumors. Additionally, calcium metabolism is frequently affected, increasing the risk of osteoporosis and bone fractures.

Musculoskeletal System: Long-term prednisone therapy can cause osteoporosis, reducing bone density and increasing fracture risk. Muscle tissue may weaken (steroid myopathy), leading to muscle weakness and joint pain. In rare cases, it can cause avascular necrosis of the femoral or humeral head, resulting in severe joint damage.

Immune System and Infections: Since prednisone suppresses immune function, patients become more susceptible to infections. Frequent colds, reactivation of herpes, and severe bacterial or fungal infections are common. Furthermore, infections may present atypically due to the blunted immune response, delaying diagnosis and treatment.

Gastrointestinal Tract: Glucocorticoids increase the risk of gastric and duodenal ulcers as well as gastrointestinal bleeding. Prednisone can irritate the stomach lining, so it is recommended to take it with food. Other possible side effects include pancreatitis, increased appetite, and nausea.

Cardiovascular System: Sodium and fluid retention may lead to edema and elevated blood pressure. Long-term therapy can cause dyslipidemia (high cholesterol levels), increasing the risk of atherosclerosis and cardiovascular complications.

Nervous System and Mental Health: Prednisone can affect mood and behavior. Some patients experience insomnia, nervousness, and mood swings ranging from euphoria to depression. High doses may trigger steroid psychosis, irritability, and cognitive impairments. Upon dose reduction after long-term therapy, some individuals experience withdrawal symptoms, including fatigue and depressive states.

Vision: Long-term prednisone use increases the risk of cataracts (clouding of the eye’s lens) and glaucoma (elevated intraocular pressure). Patients on prolonged steroid therapy should undergo regular ophthalmologic evaluations.

Skin: Prednisone may cause acne, skin thinning, slow wound healing, and stretch marks (striae). The skin becomes more fragile, making bruising more common.

Many of these side effects depend on the dose and duration of treatment. Short-term courses (several days) are generally well-tolerated, with minimal adverse reactions such as increased appetite and mild insomnia. Long-term therapy requires close monitoring and supportive measures, such as calcium and vitamin D supplementation to prevent osteoporosis. If prednisone is used for more than a week, it should never be stopped abruptly—doing so may cause adrenal insufficiency, as the body adapts to external steroid supplementation and temporarily reduces its own cortisol production. To prevent withdrawal symptoms, the dosage must be tapered gradually, allowing the adrenal glands to regain normal function.

Who Should Not Take Prednisone and Why?

Despite its significant therapeutic benefits, there are specific conditions where prednisone is contraindicated or requires extreme caution:

Infections: Prednisone should **never** be used in patients with systemic fungal infections—suppressing the immune system without concurrent antifungal therapy can lead to uncontrolled infection spread. It is also contraindicated in severe active viral infections (e.g., disseminated herpes zoster). In general, any infection requires careful evaluation before prescribing prednisone.

Live Vaccination: Patients receiving immunosuppressive doses of prednisone should not receive live vaccines (such as measles, rubella, or polio vaccines). Steroids can render vaccination ineffective and, in some cases, lead to vaccine-derived infection due to weakened immunity.

Hypersensitivity: Although rare, an allergy to prednisone or its excipients is an absolute contraindication. If a patient has previously experienced a hypersensitivity reaction (e.g., rash, swelling, or anaphylaxis), prednisone should be avoided.

Peptic Ulcer Disease: In cases of active gastric or duodenal ulcers, prednisone can exacerbate mucosal damage and increase the risk of gastrointestinal bleeding. If absolutely necessary, it is used alongside protective medications (e.g., proton pump inhibitors).

Psychiatric Disorders: Patients with uncontrolled psychosis or severe depression may experience worsening symptoms when taking steroids. Unless absolutely necessary, prednisone should be avoided in these cases.

Recent Surgeries and Injuries: Prednisone slows wound healing. In the postoperative period or after major injuries, it is used cautiously due to the risk of impaired tissue regeneration.

Besides absolute contraindications, prednisone requires caution in patients with hypertension, diabetes, osteoporosis, or pregnancy. In some critical conditions—such as anaphylactic shock or angioedema—its life-saving benefits outweigh the risks, making its administration necessary despite potential adverse effects.

Unique Aspects of Prednisone Use in Medicine

Prodrug Nature: Prednisone itself is inactive in the body—it must be converted in the liver to prednisolone, which exerts the therapeutic effect. In patients with severe liver disease, this activation process may be impaired, necessitating the direct use of prednisolone instead.

Essential Medication Status: Prednisone is included in the World Health Organization’s (WHO) list of essential medicines, underscoring its global medical significance.

Veterinary Applications: Prednisone (and particularly prednisolone) is widely used in veterinary medicine. It is prescribed for pets suffering from allergies, autoimmune diseases, and hematological disorders. However, dosage and sensitivity vary among animals, so only a veterinary specialist should manage treatment.

Short Courses Minimize Risk: A common medical saying is, “If you fear steroids, you shouldn’t practice medicine,” reflecting the hesitation some patients have about side effects. However, when used correctly—short-term and under supervision—prednisone is relatively safe. Many individuals have taken it for short durations (e.g., 3–5 days for severe colds, bronchitis, or dental pain) without experiencing any long-term effects.

Withdrawal Effect: Abrupt discontinuation after long-term use can lead to withdrawal symptoms such as weakness, loss of appetite, vomiting, pain, and hypotension—signs of acute adrenal insufficiency. To prevent this, physicians always taper the dose gradually, allowing the body to adjust. While this principle is well understood today, early in the corticosteroid era, abrupt withdrawals led to severe crises in some patients, highlighting the necessity of controlled discontinuation.

Conclusion

Prednisone rightfully remains one of the most significant medications in modern medicine. Its introduction revolutionized the treatment of numerous diseases, from rheumatism to asthma. Thanks to prednisone, millions of patients worldwide have been given the opportunity to live a normal life, free from debilitating pain and inflammation. At the same time, its widespread use has taught the medical community the importance of carefully managing side effects and adopting a balanced approach to therapy.

Prednisone continues to be an irreplaceable medication for acute conditions and severe autoimmune diseases, earning its place among life-saving drugs. When used with proper knowledge and responsibility, it provides immense benefits, serving as a remarkable example of how scientific discovery can be successfully translated into practical medicine.