Published: 3 June 2021

Publications

Prednisone treatment – follow dosing recommendations

Published: 3 June 2021
Prescriber Update 42(2): 21–22
June 2021

Background

The Health and Disability Commissioner (HDC) recently notified Medsafe of a case concerning a patient who experienced steroid withdrawal symptoms after taking high-dose prednisone for an infective exacerbation of asthma.¹ The patient told HDC that she was suffering from prednisone withdrawal symptoms, including shaking, sweats, fatigue, puffy face and swollen legs.¹

Dosing of prednisone

Prednisone dosing should be determined on case-by-case basis taking into consideration the condition being treated and its severity, the patient’s weight and comorbidities, and interactions with other medicines.^2,3 In general, prednisone should be used at the lowest effective dose and for the shortest duration. Local clinical guidelines should be consulted for the appropriate regimen for specific conditions.

Stopping prednisone

Prolonged use of prednisone can result in suppression of the hypothalamic-pituitary-adrenal axis. Abrupt cessation or a too-rapid withdrawal of prednisone may cause symptoms of adrenal insufficiency,⁴ such as abdominal pain, nausea, diarrhoea, weakness and hypotension.⁵

The need for gradual prednisone withdrawal should be assessed on a case-by-case basis. Generally, dose tapering is required for patients who have:⁴

• received more than 40 mg of prednisone per day for more than one week
• been given repeat prednisone doses in the evening
• received prednisone for more than 3 weeks
• have recently had repeated courses
• have taken a short course within one year of stopping long-term therapy
• have other possible causes of adrenal suppression.

During corticosteroid withdrawal the dose may be reduced rapidly down to physiological doses (equivalent to prednisolone 7.5 mg daily) and then reduced more slowly. Assessment of the condition being treated may be needed during withdrawal to ensure that relapse does not occur.⁴

It is important to provide clear written instructions to the patient about when and how to stop prednisone, including detailed instructions for dose tapering if required.

References

1. Health & Disability Commissioner. 2021. Prescription error for woman with respiratory complaint. URL: www.hdc.org.nz/decisions/search-decisions/2021/19hdc01826/ (accessed 16 April 2021).
2. UpToDate. Prednisone: drug information Topic 9809 version 480.0. URL: uptodate.com/contents/prednisone-drug-information (accessed 16 April 2021).
3. Asthma and Respiratory Foundation NZ. 2020. NZ Adolescent & Adult Asthma Guidelines 2020. URL: nzrespiratoryguidelines.co.nz/uploads/8/3/0/1/83014052/arfnz_adolescent_and_adult_asthma_guidelines_.pdf (accessed 25 March 2021).
4. New Zealand Formulary (NZF). 2021. NZF v107: Cautions and contra-indications of corticosteroids 1 May 2021. URL: nzf.org.nz/nzf_3812 (accessed 5 May 2021).
5. Nieman, LK. 2018. Clinical manifestations of adrenal insufficiency in adults. In: UpToDate 26 October 2018. URL: uptodate.com/contents/clinical-manifestations-of-adrenal-insufficiency-in-adults (accessed 5 May 2021).