Prednisolone

Corticosteroids: Used for anti-inflammatory and immunosuppressive effects in numerous clinical conditions (see comments below).

Disease Modifying Antirheumatic Drugs (DMARD): Immunosuppression by inhibiting T cells. Also reduces transcription of many pro-inflammatory cytokines, including TNFα, IL-1 and IFNγ. Also has important anti-inflammatory action by suppressing transcription of COX-2, and inhibiting pro-inflammatory phospholipase A2 by inducing lipocortin. Depresses cell-mediated and antibody-mediated immune reactions via cytotoxic actions on dividing cells.

COPD: Prednisolone is an oral corticosteroid that reduces airway inflammation and the release of inflammatory mediators. It is generally used short-term in an acute exacerbation of COPD but is sometimes used as maintenance in severe cases. In chronic obstructive pulmonary disease prednisolone 30 mg daily should be given for 7–14 days; treatment can be stopped abruptly. Prolonged treatment with oral prednisolone is of no benefit and maintenance treatment is not normally recommended. Prednisolone is also used widely in the treatment of other inflammatory disorders such as COPD, inflammatory bowel disease, inflammatory arthritis and arteritis.

Eye: Chronic allergic and inflammatory conditions of the uvea, iris, conjunctiva and optic nerves of the eyes may be treated with prednisolone.

IBD (Inflam bowel disease): reduction in inflammation and associated symptoms.

Bronchial asthma: Prednisolone is an oral corticosteroid that reduces airway inflammation and the release of inflammatory mediators. It is generally used short-term in an acute exacerbation of asthma. An acute attack of asthma should be treated with a short course of an oral corticosteroid starting with a high dose, e.g. prednisolone 40 mg daily for a few days. Patients whose asthma has deteriorated rapidly usually respond quickly to corticosteroids. The dose can usually be stopped abruptly in a mild exacerbation of asthma but it should be reduced gradually in those with poorer asthma control, to reduce the possibility of serious relapse. In chronic continuing asthma, when the response to other drugs has been inadequate, longer term administration of an oral corticosteroid may be necessary; in such cases high doses of an inhaled corticosteroid should be continued to minimise oral corticosteroid requirements. In chronic obstructive pulmonary disease prednisolone 30 mg daily should be given for 7–14 days; treatment can be stopped abruptly. Prolonged treatment with oral prednisolone is of no benefit and maintenance treatment is not normally recommended. Prednisolone is also used widely in the treatment of other inflammatory disorders such as COPD, inflammatory bowel disease, inflammatory arthritis and arteritis.

Corticosteroids: Prednisolone and other corticosteroids have numerous potential adverse effects if used in moderate to high dose over a prolonged period. These exaggerate some of the normal physiological actions of corticosteroids leading to mineralocorticoid and glucocorticoid side-effects. Mineralocorticoid side-effects include hypertension, sodium and water retention and potassium loss. They are most marked with fludrocortisone, but are significant with cortisone, hydrocortisone, corticotropin, and tetracosactide (tetracosactrin). Mineralocorticoid actions are negligible with the high potency glucocorticoids, betamethasone and dexamethasone, and occur only slightly with methylprednisolone, prednisolone, and triamcinolone. Glucocorticoid side-effects include diabetes and osteoporosis, which is a danger, particularly in the elderly, as it may result in osteoporotic fractures for example of the hip or vertebrae; in addition high doses are associated with avascular necrosis of the femoral head. Mental disturbances may occur; a serious paranoid state or depression with risk of suicide may be induced, particularly in patients with a history of mental disorder. Euphoria is frequently observed. Muscle wasting (proximal myopathy) may also occur. Corticosteroid therapy is also weakly linked with peptic ulceration (the potential advantage of soluble or enteric-coated preparations to reduce the risk is speculative only). High doses of corticosteroids may cause Cushing's syndrome, with moon face, striae, and acne; it is usually reversible on withdrawal of treatment, but this must always be gradually tapered to avoid symptoms of acute adrenal insufficiency. For all of these reasons the decision to treat must include a careful analysis of the potential benefits weighed against these adverse effects. Once initiated on treatment patients must be very carefully monitored.

Disease Modifying Antirheumatic Drugs (DMARD): Short-term side effects, as with all glucocorticoids, include high blood glucose levels and mineralocorticoid effects such as fluid retention. Long term side effects include Cushing's syndrome, weight gain, osteoporosis, thinning of the skin, glaucoma, susceptibility to opportunistic infections (eg. herpes zoster, tubeculosis) and type II diabetes mellitus. Adrenal suppression occurs if prednisolone is taken for longer than 7 days, a condition which means the body is unable to synthesise natural corticosteroids and becomes dependent on the prednisolone taken by the patient. For this reason, prednisolone cannot be stopped abruptly if taken for longer than seven days, but needs to be reduced slowly; this reduction may be over a few days if the course of prednisolone was short, but may take weeks or months if the patient has been on long-term steroid treatment. Abrupt withdrawal will lead to an Addisonian crisis, which may be life-threatening. Also causes growth suppression in children. See eBNF

COPD: Prednisolone (and other corticosteroid) side-effects are minimised by using lowest effective dose for minimum period possible. Gastro-intestinal effects include dyspepsia, peptic ulceration (with perforation), acute pancreatitis, oesophageal ulceration and candidiasis. Musculoskeletal effects include proximal myopathy, osteoporosis, vertebral and long bone fractures, avascular osteonecrosis, tendon rupture. Endocrine effects include adrenal suppression, menstrual irregularities and amenorrhoea, Cushing's syndrome (with high doses, usually reversible on withdrawal), hirsutism, weight gain, negative nitrogen and calcium balance, increased appetite. Increased susceptibility to and severity of infection. Neuropsychiatric effects include euphoria, psychological dependence, depression, insomnia, increased intracranial pressure with papilloedema in children (usually after withdrawal), psychosis and aggravation of schizophrenia, aggravation of epilepsy. Ophthalmic effects include glaucoma, papilloedema, posterior subcapsular cataracts, corneal or scleral thinning and exacerbation of ophthalmic viral or fungal disease. Other side-effects include impaired healing, skin atrophy, bruising, striae, telangiectasia, acne, myocardial rupture following recent myocardial infarction, fluid and electrolyte disturbance, leucocytosis.

Eye: see BNF Dose: see BNF.

IBD (Inflam bowel disease): Prednisolone (and other corticosteroid) side-effects are minimised by using lowest effective dose for minimum period possible. Gastro-intestinal effects include dyspepsia, peptic ulceration (with perforation), acute pancreatitis, oesophageal ulceration and candidiasis. Musculoskeletal effects include proximal myopathy, osteoporosis, vertebral and long bone fractures, avascular osteonecrosis, tendon rupture. Endocrine effects include adrenal suppression, menstrual irregularities and amenorrhoea, Cushing's syndrome (with high doses, usually reversible on withdrawal), hirsutism, weight gain, negative nitrogen and calcium balance, increased appetite. Increased susceptibility to and severity of infection. Neuropsychiatric effects include euphoria, psychological dependence, depression, insomnia, increased intracranial pressure with papilloedema in children (usually after withdrawal), psychosis and aggravation of schizophrenia, aggravation of epilepsy. Ophthalmic effects include glaucoma, papilloedema, posterior subcapsular cataracts, corneal or scleral thinning and exacerbation of ophthalmic viral or fungal disease. Other side-effects include impaired healing, skin atrophy, bruising, striae, telangiectasia, acne, myocardial rupture following recent myocardial infarction, fluid and electrolyte disturbance, leucocytosis.

Bronchial asthma: testinal effects include dyspepsia, peptic ulceration (with perforation), acute pancreatitis, oesophageal ulceration and candidiasis. Musculoskeletal effects include proximal myopathy, osteoporosis, vertebral and long bone fractures, avascular osteonecrosis, tendon rupture. Endocrine effects include adrenal suppression, menstrual irregularities and amenorrhoea, Cushing's syndrome (with high doses, usually reversible on withdrawal), hirsutism, weight gain, negative nitrogen and calcium balance, increased appetite. Increased susceptibility to and severity of infection. Neuropsychiatric effects include euphoria, psychological dependence, depression, insomnia, increased intracranial pressure with papilloedema in children (usually after withdrawal), psychosis and aggravation of schizophrenia, aggravation of epilepsy. Ophthalmic effects include glaucoma, papilloedema, posterior subcapsular cataracts, corneal or scleral thinning and exacerbation of ophthalmic viral or fungal disease. Other side-effects include impaired healing, skin atrophy, bruising, striae, telangiectasia, acne, myocardial rupture following recent myocardial infarction, fluid and electrolyte disturbance, leucocytosis.

Corticosteroids: Prednisolone is given by mouth, initially, 10–20 mg daily (but in severe disease up to 60 mg daily) in the morning after breakfast. Dose reduced within a few days but may need to be continued for several months. Maintenance 2.5–15 mg daily, but higher doses may be needed. 'Cushingoid' side-effects increasingly likely with doses above 7.5 mg daily and above these dose bisphosphonate prophylaxis against corticosteroid-induced osteoporosis is often recommended.

Disease Modifying Antirheumatic Drugs (DMARD): Dosage requirements vary among individuals and the activity of the disease. The lowest possible effective dose is used because of the potential for adverse effects. See eBNF

COPD: Taken by mouth, initially, up to 10–20 mg daily, preferably taken in the morning after breakfast; can often be reduced within a few days but may need to be continued for longer. Rarely needed as maintenance in asthma. Cushingoid side-effects increasingly likely with doses above 7.5 mg daily. Can also be given by IM injection. An oral corticosteroid such as prednisolone should normally be taken as a single dose in the morning to reduce the disturbance to circadian cortisol secretion. Dosage should always be titrated to the lowest dose that controls symptoms. Regular peak flow measurements help to optimise the dose.

Eye: See BNF.

IBD (Inflam bowel disease): See eBNF.

Bronchial asthma: Taken by mouth, initially, up to 10–20 mg daily (severe disease, up to 60 mg daily), preferably taken in the morning after breakfast; can often be reduced within a few days but may need to be continued for longer. Rarely needed as maintenance in asthma. Cushingoid side-effects increasingly likely with doses above 7.5 mg daily. Can also be given by IM injection. An oral corticosteroid such as prednisolone should normally be taken as a single dose in the morning to reduce the disturbance to circadian cortisol secretion. Dosage should always be titrated to the lowest dose that controls symptoms. Regular peak flow measurements help to optimise the dose. Alternate-day administration has not been very successful in the management of asthma in adults because control can deteriorate during the second 24 hours. If alternate-day administration is introduced, pulmonary function should be monitored carefully over the 48 hours.

Corticosteroids: Numerous potential interactions. See BNF.

Disease Modifying Antirheumatic Drugs (DMARD): See eBNF.

COPD: See eBNF.

Eye: See BNF.

IBD (Inflam bowel disease): See eBNF.

Bronchial asthma: See eBNF.

Corticosteroids: Fludrocortisone is a corticosteroid with predominantly mineralocorticoid activity. CUSHING'S DISEASE. This is a rare disease of excess production of corticosteroids from the adrenal cortex and this can be suppressed by the drugs metyrapone and aminoglutethimide. Prednisolone has predominantly glucocorticoid activity and is the corticosteroid most commonly used by mouth for long-term disease suppression. . The need to avoid abrupt withdrawal is highlighted on the 'steroid treatment card' given to all patients on corticosteroids. Dexamethasone is a potent synthetic member of the glucocorticoid class of steroid hormones. It acts as an anti-inflammatory and immunosuppressant. Its potency is about 40 times that of hydrocortisone.

Disease Modifying Antirheumatic Drugs (DMARD): Prednisolone is effective at suppressing activity in rheumatoid arthritis but is used with caution and avoided as chronic therapy if possible because of many undesirable effects (see above), particularly osteoporosis. Corticosteroids are often given locally by intra-articular injection to provide relief in badly affected joints. Prednisolone is used to suppress inflammation in many inflammatory and allergic conditions as well as rheumatoid arthritis. Examples include systemic lupus, acute gouty arthritis, psoriatic arthritis, ulcerative colitis, and Crohn's disease. Severe allergic conditions that fail conventionaltreatment may also respond to prednisolone. Examples include bronchial asthma, allergic rhinitis, drug-induced dermatitis, and contact and atopic dermatitis. Chronic allergic and inflammatory conditions of the uvea, iris, conjunctiva and optic nerves of the eyes are also treated with prednisolone.Prednisolone is also used in the treatment of blood cell cancers (leukemias), and lymph gland cancers (lymphomas). Blood diseases involving destruction of platelets by the body's own immune cells (idiopathic thrombocytopenia purpura), and destruction of red blood cells by immune cells (autoimmune hemolytic anemia) can also be treated with prednisolone. Other miscellaneous conditions treated with this medication include thyroiditis and sarcoidosis. Finally, prednisolone is used as a hormone replacement in patients whose adrenal glands are unable to produce sufficient amounts of corticosteroids.

Eye: 1 always remind the patient to keep their eyes shut for 30 seconds after instillation of the drops, blinking results in the drug being pumped out the conjunctival sac within 10 seconds severely reducing its absorption 2 use drops during the day and the ointment equivalent at night to optimise the treatment 3 the drugs mentioned in this section all topical (eye drops) agents, oral agents are infrequently used and information on these drugs can be found elsewhere in the e-drug formulary.

IBD (Inflam bowel disease): actions can be localized via enema or suppository.