Systemic corticosteroids · Endocrine
Prednisone
prednisolone (active form) · Deltasone® · Winpred®(brand names vary by market)
The most useful drug on the ward, and the one that quietly does the most damage.
Also: oral liquid
Mechanism
A prodrug converted to prednisolone, which binds the glucocorticoid receptor and alters transcription of hundreds of genes: less cytokine production, less leukocyte trafficking, and effects on glucose, bone, mood and the adrenal axis that come with it.
Indications
- Asthma and COPD exacerbations
- Autoimmune and inflammatory disease
- Giant cell arteritis and polymyalgia rheumatica
- Transplant and haematological protocols
- Adrenal insufficiency, in combination
Formulations
Dosing concepts
Short course
Courses of under about three weeks can usually be stopped abruptly, because the adrenal axis has not had time to suppress.
Long course
Beyond roughly three weeks, or with repeated courses, the axis is suppressed and the drug is tapered. The taper is not about the disease, it is about the adrenal gland.
Timing
Given in the morning to mirror the natural cortisol rhythm and reduce insomnia.
Sick days
A patient on long-term steroids who becomes ill needs MORE, not less; that is the opposite of the instinct and it is life-saving.
Concepts, not prescribing instructions. Practice numbers live in current references and local protocols.
Pharmacokinetics
- Bioavailability
- ~80%
- Half-life
- Plasma 2 to 4 h; biological effect 12 to 36 h
- Elimination
- hepatic: Converted to prednisolone by the liver, so prednisolone is used directly in significant liver disease
- Protein binding
- ~70 to 90%
Adverse effects
- Hyperglycemiacommon & seriousCharacteristically afternoon and evening, so a fasting morning glucose can miss it entirely.
- Insomnia, mood change, agitation, frank psychosiscommonDose-related and often in the first week.
- Increased infection riskserious
- Osteoporosis and fractureserious
- Adrenal suppressionserious
- Weight gain, Cushingoid appearance, skin thinning, bruisingcommon
- Peptic ulceration, mainly alongside NSAIDsserious
- Cataract and glaucoma with prolonged useserious
Contraindications & precautions
Contraindications
- Systemic fungal infection
- Live vaccines at immunosuppressive doses
Precautions
- Diabetes
- Peptic ulcer disease or concurrent NSAIDs
- Psychiatric history
- Osteoporosis
- Latent tuberculosis or hepatitis B
Interactions
Monitoring
Glucose
Steroid hyperglycemia is near-universal at higher doses and often missed · From the first days in anyone diabetic or at risk, using afternoon readings
Blood pressure and weight
Fluid retention and metabolic effects
Bone protection assessment
Anything beyond about three months warrants calcium, vitamin D and a bisphosphonate discussion
Mood and sleep
Common, distressing, and rarely asked about
Counselling points
- Take it in the morning, with food.
- Do not stop it suddenly if you have been on it for more than a few weeks; the dose is reduced gradually.
- Carry a steroid card, and tell any clinician treating you that you take it.
- If you become unwell, contact us: the dose usually needs to go up, not down.
- You may feel unusually awake, irritable or hungry. Tell us if your mood changes markedly.
- Report any sign of infection promptly, and stay away from chickenpox and measles if you have not had them.
Clinical pearls
- Steroid-induced hyperglycemia peaks in the afternoon and evening. Checking only a fasting glucose is the standard way to miss it, and insulin regimens for it are shaped accordingly.
- The single most dangerous moment in long-term steroid therapy is an intercurrent illness during which the patient reduces the dose because they feel unwell.
- Prednisone requires hepatic conversion to prednisolone; in significant liver disease, prednisolone is prescribed directly.
References & review
- Prednisone product monograph (consult the current version for your market) (monograph)
- Goodman & Gilman's The Pharmacological Basis of Therapeutics, 14th ed. (reference-work)
Last reviewed 2026-08-16 · jurisdiction: global · drug information changes; verify against current references before practice use.