Prednisone

1. Prednisone Jessica Skutnik Nur 555

2. Objectives • The purpose of this presentation is to understand the indications for prescribing prednisone, the dosing schedule, side effects to be aware of, and ways to possibly avoid these side effects

3. Prednisone • Prednisone is a corticosteroid that is very similar to cortisol, a hormone produced by the hypothalamic-anterior pituitary-adrenocortical axis. • Prednisone can be used to replace deficiencies when the body does not produce enough independently

4. Pharmacokinetics • Well absorbed orally • Prednisone is inactive and metabolized into prednisolone by the liver • Half life is 3.4-3.8 hours in plasma 18-36 hours in tissue • Adrenal suppression lasts 1.25-1.5 days

5. Indications • Prednisone relieves inflammation, and is used to treat numerous conditions such as certain forms of arthritis; skin, blood, kidney, eye, thyroid and intestinal disorders; severe allergies; and asthma. Prednisone is also used in conjunction with other drugs in transplant cases and with certain cancers.

6. Contraindications • Systemic fungal infections • Hypersensitivity to the drug • Administration of live virus vaccines (smallpox) in patients receiving immunosuppressive corticosteroid doses

7. How Supplied • Prednisone is supplied in tablet, solution, concentrate and syrup. • May instruct patient to follow a low-sodium, potassium-rich or high protein diet. If abdominal pain or upset stomach occur, prednisone can be taken with food or milk.

8. Dosing Time • The activity of the adrenal cortex is naturally highest between 2 am and 8 am. • The lowest activity levels occur between 4 pm and midnight. • Exogenous corticosteroids supress adrenocortical the least when given during the time of maximal natural activity. • Doses should be given before 9 am

9. Initiating Therapy • Therapy is initiated based on the specific condition being treated. • Daily dose may range from 5-60 mg depending on condition being treated • Dose is maintained or adjusted to obtain maximal results. If positive results are not obtained then prednisone is discontinued and another medication is initiated.

10. Maintenance Dose • Maintenance doses should be at the lowest possible level to achieve the desired therapeutic effect. • Constant monitoring of drug level is required

12. Dose Adjustment Situations where dose adjustment may need to be closely monitored include: • Changes in disease process • Patient’s individual drug responsiveness • Effect of patient exposure to stress

13. Withdrawing Therapy • When taking patients off oral prednisone the dose must be decreased gradually to allow the patient’s own hypothalamic-anterior-pituitary-adrenocortical axis to function on its own

14. Side Effects • Uncommon side effects include: upset stomach, stomach irritation, vomiting, headache, dizziness, insomnia, restlessness, depression, anxiety, acne, increased hair growth, easy bruising, irregular or absent menstrual periods

15. Severe Side Effects • Skin rash • Swollen face, lower legs, or ankles • Vision problems • Cold or infection that lingers • Muscle weakness • Black or tarry stools

16. Potentially Associated Side Effects • Accelerated atherosclerotic disease • Acne • Cataracts • CHF/fluid retention • Diabetes/insulin resistance • Glaucoma • Hypertension • Increased risk for infections • Mood changes • Myopathy • Osteonecrosis • Osteoporosis and fracture • Peptic ulcer disease • Skin bruising and thinning • Sleep disturbances • Weight gain

17. How do we avoid these side effects? • Sources say every other day dosing decreases the side effects. • Every other day dosing is anticipated in patients who are expected to be on long term therapy • Every other day dosing does reduce infection, cushingoid skin changes and the hypothalamic-pituitary-adrenal (HPA) axis suppression

18. HOWEVER!!! Every other day dosing does NOT protect: • Bone health • Against cataracts AND patients may have flare ups on “off” days

19. Osteoporosis and fracture • Osteoporotic fractures have been reported in as many as 50% of patients receiving long term therapy. • More than 50% of patients with hip fracture do not fully recover, and 25% require long term nursing-home care. • 24% die within the first year

20. Pregnancy • Prednisone is safe to use in pregnancy when inflammatory disorders typically flare, as a temporary substitute. ex: SLE often flares during pregnancy, the SLE-associated arthritis can be controlled in the 1st and 2nd trimester with acetaminophen or NSAIDs HOWEVER: other manifestations such as lupus nephritis or severe thrombocytopenia may require medication that is contraindicated in pregnancy-in this situation higher doses of prednisone are safer to use.

21. Conclusion • Prednisone is a powerful drug that needs careful monitoring when in use • Some patients may benefit from prednisone everyday, every other day or some may not benefit at all • Health care practitioners should always be observant for long term effects of prednisone use.

22. Key Points • Oral prednisone should correlate with the body’s natural rhythm, dosing should occur before 9 am. • Prednisone is safe to use in pregnancy • Every other day dosing does not protect bone health • Multiple situations require dose adjustments

23. References Glucocorticoids. (2002). In Erwin Kastrup (ed.) Drug Facts and Comparisons. St. Louis, MO. Facts and Comparisons. Prenisone Oral (2003). Retrieved March 19, 2006 from http://www/nlm.nih.gov/medlineplus/print/druginfo/medmaster/a601102.html Saag, K., Curtis, J. (2003). Use of glucocorticoids in arthritis: 20 clinical pearls maximizing the benefits, minimizing the complications. The Journal of Musculoskeletal Medicine, 20, 425-433.