Prednisolone

Chemical formula: C₂₁H₂₈O₅  Molecular mass: 360.444 g/mol  PubChem compound: 5755

Interactions

Prednisolone interacts in the following cases:

Non-steroidal anti-inflammatory drugs (NSAIDs)

Concomitant use of Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) with corticosteroids increases the risk of gastro-intestinal bleeding and ulceration.

Salicylates

The renal clearance of salicylates is increased by corticosteroids and steroid withdrawal may result in salicylate intoxication.

CYP3A inhibitors

Co-treatment with CYP3A inhibitors, including cobicistat-containing products, is expected to increase the risk of systemic side-effects. The combination should be avoided unless the benefit outweighs the increased risk of systemic corticosteroid side-effects, in which case patients should be monitored for systemic corticosteroid side-effects.

Liver failure

Caution is necessary when corticosteroids, including prednisolone, are prescribed to patients with liver failure and frequent patient monitoring is necessary.

Renal insufficiency

Caution is necessary when corticosteroids, including prednisolone, are prescribed to patients with renal insufficiency and frequent patient monitoring is necessary.

Hypoglycaemic agents

The desired effects of hypoglycaemic agents (including insulin) are antagonised by corticosteroids.

Coumarin anticoagulants

The efficacy of coumarin anticoagulants and warfarin may be enhanced by concurrent corticosteroid therapy and close monitoring of the INR or prothrombin time is required to avoid spontaneous bleeding.

Cardiac glycosides

The toxicity of cardiac glycosides is increased if hypokalaemia occurs with corticosteroids.

Anti-hypertensives

The desired effects of anti-hypertensives are antagonised by corticosteroids.

Diuretics

The desired effects of diuretics are antagonised by corticosteroids.

Thiazide diuretics

The hypokalaemic effects of thiazide diuretics are enhanced by corticosteroids.

Loop diuretics

The hypokalaemic effects of loop diuretics are enhanced by corticosteroids.

Retinoids, tetracyclines

Corticosteroids should not be used concurrently with retinoids and tetracyclines due to increased intracranial pressure.

Oestrogens, oral contraceptives

Oestrogens and other oral contraceptives may potentiate the effects of glucocorticoids and dosage adjustments may be required if oral contraceptives are added to or withdrawn from a stable dosage regimen.

Anticholinesterases

Steroids may reduce the effects of anticholinesterases in myasthenia gravis and cholecystographic x-ray media.

Fertility

Corticosteroids may alter the motility and number of spermatozoa in certain patients.

Acetazolamide

The hypokalaemic effects of acetazolamide are enhanced by corticosteroids.

Acetylsalicylic acid

Acetylsalicylic acid should be used cautiously in conjunction with glucocorticoids in patients with hypoprothrombinaemia. Concurrent use of acetylsalicylic acid and prednisolone may result in an increased risk of gastrointestinal ulceration and sub therapeutic acetylsalicylic acid serum concentrations.

Aminogluthetimide

Aminogluthetimide enhances the metabolism of corticosteroids and its therapeutic effects may be reduced. Therefore, it may be necessary to adjust the dose of prednisolone accordingly.

Amphotericin B

There is an increased risk of hypokalaemia with amphotericin, and concomitant use with prednisolone should be avoided.

Carbamazepine

Carbamazepine enhances the metabolism of corticosteroids and its therapeutic effects may be reduced. Therefore, it may be necessary to adjust the dose of prednisolone accordingly.

Carbenoxolone

The hypokalaemic effects of carbenoxolone are enhanced by corticosteroids.

Ciclosporin

Ciclosporin increases plasma concentration of prednisolone.

Ephedrine

Ephedrine enhances the metabolism of corticosteroids and its therapeutic effects may be reduced. Therefore, it may be necessary to adjust the dose of prednisolone accordingly.

Erythromycin

Erythromycin may inhibit the metabolism of some corticosteroids.

Etoposide

Etoposide metabolism may be inhibited by corticosteroids in vitro. This may lead to an increase in both efficacy and toxicity of etoposide. Monitoring would be prudent.

Ketoconazole

Ketoconazole reduces the metabolic and renal clearance of methylprednisolone and this may also occur with prednisolone.

Methotrexate

Concomitant use of prednisolone with methotrexate may increase the risk of haematological toxicity.

Mifepristone

Mifepristone may reduce the effect of corticosteroids for 3-4 days.

Phenobarbital

Phenobarbital enhances the metabolism of corticosteroids and its therapeutic effects may be reduced. Therefore, it may be necessary to adjust the dose of prednisolone accordingly.

Phenytoin

Phenytoin enhances the metabolism of corticosteroids and its therapeutic effects may be reduced. Therefore, it may be necessary to adjust the dose of prednisolone accordingly.

Primidone

Primidone enhances the metabolism of corticosteroids and its therapeutic effects may be reduced. Therefore, it may be necessary to adjust the dose of prednisolone accordingly.

Rifabutin

Rifabutin enhances the metabolism of corticosteroids and its therapeutic effects may be reduced. Therefore, it may be necessary to adjust the dose of prednisolone accordingly.

Rifampicin

Rifampicin enhances the metabolism of corticosteroids and its therapeutic effects may be reduced. Therefore, it may be necessary to adjust the dose of prednisolone accordingly.

Ritonavir

Ritonavir may increases plasma concentration of prednisolone.

Somatropin

The growth promoting effect of somatropin may be inhibited by the concomitant use of corticosteroids.

Theophylline

There is also an increased risk of hypokalaemia with the simultaneous use of theophylline and if high doses of corticosteroids are given with high doses of bambuterol, fenoterol, formoterol, ritodrine, salbutamol, salmeterol and terbutaline.

Peptic ulceration

Caution is necessary when corticosteroids, including prednisolone, are prescribed to patients with peptic ulceration and frequent patient monitoring is necessary.

Recent myocardial infarction (rupture)

Caution is necessary when corticosteroids, including prednisolone, are prescribed to patients with recent myocardial infarction (rupture) and frequent patient monitoring is necessary.

Scleroderma renal crisis

Caution is required in patients with systemic sclerosis because of an increased incidence of (possibly fatal) scleroderma renal crisis with hypertension and decreased urinary output observed with a daily dose of 15 mg or more prednisolone. Blood pressure and renal function (s-creatinine) should therefore be routinely checked. When renal crisis is suspected, blood pressure should be carefully controlled.

Adrenal cortical atrophy

Adrenal cortical atrophy develops during prolonged therapy with prednisolone and may persist for years after stopping treatment.

Glaucoma

Caution is necessary when corticosteroids, including prednisolone, are prescribed to patients with glaucoma or in those with a family history of glaucoma and frequent patient monitoring is necessary.

Steroid-induced myopathy

Caution is necessary when corticosteroids, including prednisolone, are prescribed to patients with previous steroid myopathy and frequent patient monitoring is necessary.

Hypertension

Caution is necessary when corticosteroids, including prednisolone, are prescribed to patients with hypertension and frequent patient monitoring is necessary.

Hypothyroidism

The effect of corticosteroids may be enhanced in patients with hypothyroidism in those with chronic liver disease with impaired hepatic function.

Congestive heart failure

Caution is necessary when corticosteroids, including prednisolone, are prescribed to patients with congestive heart failure and frequent patient monitoring is necessary.

Tuberculosis

Caution is necessary when corticosteroids, including prednisolone, are prescribed to patients with a history of, or X-ray changes characteristic of tuberculosis. The emergence of active tuberculosis can, however, be prevented by the prophylactic use of antituberculous therapy.

Osteoporosis

Caution is necessary when corticosteroids, including prednisolone, are prescribed to patients withs oteoporosis and frequent patient monitoring is necessary. This is of special importance in post-menopausal females who are at particular risk.

Psychotic disorder

Caution is necessary when corticosteroids, including prednisolone, are prescribed to patients with a history of severe affective disorders and particularly those with a previous history of corticosteroid induced psychoses and frequent patient monitoring is necessary.

Diabetes mellitus

Caution is necessary when corticosteroids, including prednisolone, are prescribed to patients with diabetes mellitus or in those with a family history of diabetes and frequent patient monitoring is necessary.

Epilepsy

Caution is necessary when corticosteroids, including prednisolone, are prescribed to patients with epilepsy and frequent patient monitoring is necessary.

Pregnancy

The ability of corticosteroids to cross the placenta varies between individual drugs, however 88% of prednisolone is inactivated as it crosses the placenta.

Administration of corticosteroids to pregnant animals can cause abnormalities of foetal development including cleft palate, intra-uterine growth retardation and effects on brain growth and development. There is no evidence that corticosteroids result in an increased incidence of congenital abnormalities, such as cleft palate/lip in man. However, when administered for prolonged periods or repeatedly during pregnancy, corticosteroids may increase the risk of intrauterine growth retardation. Hypoadrenalism may occur in the neonate following prenatal exposure to corticosteroids but usually resolves spontaneously following birth and is rarely clinically important. Cataracts have also been rarely reported. As with all drugs, corticosteroids should only be prescribed when the benefits to the mother and child outweigh the risks. When corticosteroids are essential, however, patients with abnormal pregnancies may be treated as though they were in the non-gravid state.

Patients with pre-eclampsia or fluid retention require close monitoring.

Depression of hormone levels has been described in pregnancy but the significance of this finding is not clear.

Nursing mothers

Corticosteroids are excreted in small amounts in breast milk where they may suppress growth and interfere with endogenous glucocorticoid production in nursing infants. Since adequate reproductive studies have not been performed in humans with glucocorticoids, these drugs should be administered to nursing mothers only if the benefits of therapy are judged to outweigh the potential risks to the infant.

The concentration of the steroid in the milk can be between 5 and 25% of those in the serum.

There are no reports found regarding neonatal toxicity following exposure to corticosteroids during lactation, however if maternal doses >40mg/day of prednisolone is prescribed, the infant should be monitored for adrenal suppression.

Carcinogenesis, mutagenesis and fertility

Fertility

Corticosteroids may alter the motility and number of spermatozoa in certain patients.

Effects on ability to drive and use machines

The effect of prednisolone on the ability to drive or use machinery has not been evaluated. There is no evidence to suggest that prednisolone may affect these abilities.

This medicine has no or negligible influence on the ability to drive and use machines.

Adverse reactions


I-ARTIC / P-ARTIC / IM injection

The incidence of predictable undesirable effects, including hypothalamo-pituitary-adrenal (HPA) suppression, correlates with the relative potency of the drug, dosage, timing of administration and the duration of treatment.

The following side effects may be associated with the long-term systemic use of corticosteroids with the following frequency: Not known (cannot be estimated from available data).

Infections and infestations

Not known: Increased susceptibility and severity of infections with suppression of clinical symptoms and signs, opportunistic infections, recurrence of dormant tuberculosis.

Neoplasms benign, malignant and unspecified (including cysts and polyps)

Not known: Kaposi’s sarcoma has been reported to occur in patients receiving corticosteroid therapy. Discontinuation of corticosteroids may result in clinical remission.

Blood and lymphatic system disorders

Not known: Leukocytosis.

Immune system disorders

Not known: Hypersensitivity including anaphylaxis has been reported.

Endocrine disorders

Not known: Suppression of the HPA axis. Cushingoid. Impaired carbohydrate intolerance with increased requirement for anti-diabetic therapy, manifestation of latent diabetes mellitus.

Metabolism and nutrition disorders

Not known: Sodium and water retention, hypokalaemia, hypokalaemic alkalosis, increased appetite, negative protein and calcium balance.

Psychiatric disordersa

Not known: Euphoric mood, psychological dependence, depressed mood, insomnia, aggravation of schizophrenia.

Nervous system disorders

Not known: Dizziness, headache. Aggravation of epilepsy.

Eye disorders

Not known: Glaucoma, papilloedema, posterior subcapsular cataracts, central serous chorioretinopathy, exophthalmos, corneal or scleral thinning, exacerbation of ophthalmic viral or fungal diseases and vision, blurred.

Ear and labyrinth disorders

Not known: Vertigo.

Cardiac disorders

Not known: Myocardial rupture following recent myocardial infarction. Congestive cardiac failure (in susceptible patients).

Vascular disorders

Not known: Hypertension, embolism.

Respiratory, thoracic and mediastinal disorders

Not known: Hiccups.

Gastrointestinal disorders

Not known: Dyspepsia, nausea, vomiting, abdominal distension, abdominal pain, diarrhoea, oesophageal ulceration, candidiasis, pancreatitis acute. Peptic ulceration with perforation and haemorrhage.

Skin and subcutaneous tissue disorders

Not known: Skin Atrophy, skin striae, acne, telangiectasia, hyperhidrosis, rash, pruritus, urticaria, hirsutism.

Musculoskeletal and connective tissue disorders

Not known: Myopathy, osteoporosis, vertebral and long bone fractures, avascular osteonecrosis, myalgia.

Renal and urinary disorders

Not known: Scleroderma renal crisis*

Reproductive system and breast disorders

Not known: Menstruation irregular, amenorrhoea.

General disorders and administration site conditions

Not known: Impaired healing, malaise.

Investigations

Not known: Weight increased.

Injury, poisoning and procedural complications

Not known: Tendon rupture, contusion (bruising).

a A wide range of psychiatric reactions including affective disorders (such as irritable, euphoric, depressed and labile mood and suicidal thoughts), psychotic reactions (including mania, delusions, hallucinations and aggravation of schizophrenia), behavioural disturbances, irritability, anxiety, sleep disturbances and cognitive dysfunction including confusion and amnesia have been reported. Reactions are common and may occur in both adults and children. In adults, the frequency of severe reactions has been estimated to be 5-6%. Psychological effects have been reported on withdrawal of corticosteroids; the frequency is unknown.
* Scleroderma renal crisis: Amongst the different subpopulations the occurrence of scleroderma renal crisis varies. The highest risk has been reported in patients with diffuse systemic sclerosis. The lowest risk has been reported in patients with limited systemic sclerosis (2%) and juvenile onset systemic sclerosis (1%).

Withdrawal Symptoms

Too rapid a reduction of corticosteroid dosage following prolonged treatment can lead to acute adrenal insufficiency, hypotension and death.

A ‘withdrawal syndrome’ may also occur including fever, myalgia, arthralgia, rhinitis, conjunctivitis, painful itchy skin nodules and loss of weight.

In some instances, withdrawal symptoms may involve or resemble a clinical relapse of the disease for which the patient has been undergoing treatment.

Other effects that may occur during withdrawal or change of corticosteroid therapy include benign intracranial hypertension with headache and vomiting and papilloedema caused by cerebral oedema.

Latent rhinitis or eczema may be unmasked.

Paediatric population

Increased intracranial pressure with papilloedema in children (pseudotumour cerebri) - usually after treatment withdrawal.

Growth retardation in infancy, childhood and adolescence.

Oral administration

A wide range of psychiatric reactions including affective disorders (such as irritable, euphoric, depressed and labile mood, and suicidal thoughts), psychotic reactions (including mania, delusions, hallucinations, and aggravation of schizophrenia), behavioural disturbances, irritability, anxiety, sleep disturbances, and cognitive dysfunction including confusion and amnesia have been reported. Reactions are common and may occur in both adults and children. In adults, the frequency of severe reactions has been estimated to be 5-6%. Psychological effects have been reported on withdrawal of corticosteroids; the frequency is unknown.

The incidence of predictable undesirable effects, including hypothalamic-pituitary adrenal suppression correlates with the relative potency of the drug, dosage, timing of administration and the duration of treatment.

Undesirable effects are listed by MedDRA System Organ Classes.

Assessment of undesirable effects is based on the following frequency groupings: very common: ≥1/10, common: ≥1/100 to <1/10, uncommon: ≥1/1,000 to <1/100, rare: ≥1/10,000 to <1/1,000, very rare: <1/10,000, not known: cannot be estimated from the available data.

Infections and Infestations

Not known: Increases susceptibility to, and severity of infections1, opportunistic infections, recurrence of dormant tuberculosis, oesophageal candidiasis.

Blood and lymphatic system disorders

Not known: Leucocytosis.

Immune system disorders

Not known: Hypersensitivity including anaphylaxis.

Endocrine disorders

Not known: Suppression of the hypothalamo-pituitary adrenal axis2, cushingoid facies, impaired carbohydrate tolerance with increased requirement for antidiabetic therapy, manifestation of latent diabetes mellitus.

Metabolism and nutrition disorders

Not known: Sodium and water retention, hypokalaemic alkalosis, potassium loss, negative nitrogen and calcium balance, glucose intolerance and protein catabolism. Increase both high and low density lipoprotein cholesterol concentration in the blood. Increased appetite3. Weight gain, obesity, hyperglycaemia, dyslipidaemia.

Very rare: Calciphylaxis

Psychiatric disorders

Common: Irritability, depressed and labile mood, suicidal thoughts, psychotic reactions, mania, delusions, hallucinations, and aggravation of schizophrenia. behavioural disturbances, irritability, anxiety, sleep disturbances, and cognitive dysfunction including confusion and amnesia.

Not known: Euphoria, psychological dependence, depression.

Nervous system disorders

Not known: Depression, insomnia, dizziness, headache, vertigo. Raised intracranial pressure with papilloedema (pseudotumor cerebri)4. Aggravation of epilepsy, epidural lipomatosis. vertebrobasilar stroke5

Eye disorders

Not known: Vision blurred, glaucoma, papilloedema, posterior subcapsular cataracts, nuclear cataracts (particularly in children), exophthalmos, corneal or scleral thinning, exacerbation of ophthalmic viral or fungal disease.

Severe exacerbation of bullous exudative retinal detachment; central serous chorioretinopathy or lasting visual loss in some patients with idiopathic central serous chorioretinopathy.

Ear and labyrinth disorders

Not known: Vertigo.

Cardiac disorders

Not known: Congestive heart failure in susceptible patients, hypertension, increased risk of heart failure. Increased risk of cardiovascular disease, including myocardial infarction6.

Vascular disorders

Not known: Thromboembolism.

Gastrointestinal disorders

Not known: Dyspepsia, nausea, peptic ulceration with perforation and haemorrhage, abdominal distension, abdominal pain, diarrhoea, oesophageal ulceration, acute pancreatitis.

Skin and subcutaneous tissue disorders

Not known: Hirsutism, skin atrophy, bruising, striae, telangiectasia, acne, increased sweating, pruritis, rash, urticaria.

Musculoskeletal and connective tissue disorders

Not known: Proximal myopathy, osteoporosis, vertebral and long bone fractures, avascular osteonecrosis, tendon rupture, tendinopathies (particularly of the Achilles and patellar tendons), myalgia, growth suppression in infancy, childhood and adolescence.

Renal and urinary disorders

Not known: Scleroderma renal crisis7

Reproductive system and breast disorders

Not known: Menstrual irregularity, amenorrhoea.

General disorders and administration site conditions

Not known: Fatigue, malaise, impaired healing

Investigations

Not known: Increased intra-ocular pressure, may suppress reactions to skin tests.

1 with suppression of clinical symptoms and signs.
2 particularly in times of stress, as in trauma, surgery or illness.
3 which may result in weight gain
4 usually after treatment withdrawal
5 exacerbation of giant cell arteritis, with clinical signs of evolving stroke has been attributed to prednisolone.
6 with high dose therapy
7 amongst the different subpopulations the occurrence of scleroderma renal crises varies. The highest risk has been reported in patients with diffuse systemic sclerosis. The lowest risk has been reported in patients with limited systemic sclerosis (2%) and juvenile onset systemic sclerosis (1%)

Withdrawal symptoms

Too rapid a reduction of corticosteroid dosage following prolonged treatment can lead to acute adrenal insufficiency, hypotension and death. A steroid “withdrawal syndrome” seemingly unrelated to adrenocortical insufficiency may also occur following abrupt discontinuance of glucocorticoids. This syndrome includes symptoms such as: anorexia, nausea, vomiting, lethargy, headache, fever, joint pain, desquamation, myalgia, arthralgia, rhinitis, conjunctivitis, painful itchy skin nodules weight loss, and/or hypotension. These effects are thought to be due to the sudden change in glucocorticoid concentration rather than to low corticosteroid levels. Psychological effects have been reported on withdrawal of corticosteroids.

Rectal administration

A wide range of psychiatric reactions including affective disorder (such as irritable, euphoric, depressed and labile mood and suicidal thoughts), psychotic reactions (including mania, delusions, hallucinations and aggravation of schizophrenia), behavioural disturbances, irritability, anxiety, sleep disturbances and cognitive dysfunction including confusion and amnesia have been reported. Reactions are common any may occur in both adults and children. In adults, the frequency of severe reactions has been estimated to the 5-6%. Psychological effects have been reported on withdrawal of corticosteroids; the frequency is Not known.

The incidence of predictable undesirable effects, including hypothalamic-pituitary-adrenal (HPA) axis suppression correlates with the relative systemic potency of the drug, dosage, timing of administration and the duration of treatment.

Infections and infestations

Not known: Increased susceptibility and severity of infections with suppression of clinical symptoms and signs, opportunistic infections, recurrence of dormant tuberculosis.

Blood and lymphatic system disorders

Not known: leukemoid reactions, Leucocytosis

Immune system disorders

Not known: Hypersensitivity including anaphylaxis has been reported.

Endocrine disorders

Not known: Menstrual irregularity and amenorrhoea, Cushingoid facies, hirsutism, impaired carbohydrate tolerance with increased requirement for antidiabetic therapy. Negative protein and calcium balance.

Metabolism and nutrition disorders

Not known: Sodium and water retention, potassium loss, hypokalaemic alkalosis, increased appetite, weight gain, alteration in lipid levels (increases in total cholesterol, low density lipoproteins and triglycerides)

Psychiatric disorders

Not known: Psychological dependence

Nervous system disorders

Not known: Dizziness, headache, aggravation of epilepsy

Eye disorders

Not known: Increased intra-ocular pressure, glaucoma, papilloedema, posterior subcapsular cataracts, corneal or scleral thinning and exacerbation of ophthalmic viral or fungal diseases. Chorioretinopathy. Vision, blurred

Cardiac disorders

Not known: Myocardial rupture following recent myocardial infarction.

Vascular disorders

Not known: Hypertension, Thromboembolism

Gastrointestinal disorders

Not known: Nausea, hiccups, dyspepsia, peptic ulceration with perforation and haemorrhage, acute pancreatitis, candidiasis.

Skin and subcutaneous tissue disorders

Not known: Skin atrophy, bruising, telangiectasia, striae, acne, dermatitis and toxic epidermal necrolysis.

Musculoskeletal and connective tissue disorders

Not known: Osteoporosis, vertebral and long bone fractures, avascular osteonecrosis, tendon rupture, proximal myopathy.

General disorders and administration site conditions

Not known: Impaired healing

Withdrawal symptoms and signs

Too rapid a reduction of corticosteroid dosage following prolonged treatment can lead to acute adrenal insufficiency, hypotension and in severe cases this could be fatal.

A ‘withdrawal syndrome’ may also occur including; fever, myalgia, arthralgia, rhinitis, conjunctivitis, painful itchy skin nodules and loss of weight.

Paediatric population

Suppression of the hypothalamic-pituitary-adrenal axis, growth suppression in infancy, childhood and adolescence.

Increased intracranial pressure with papilloedema in children (pseudotumor cerebri), usually after treatment withdrawal.

Ocular administration

Eye disorders

Not known: vision, blurred

Prolonged treatment with corticosteroids in high dosage is occasionally associated with cataract.

The systemic effects of steroids are possible following the use of prednisolone, but are, however, unlikely due to the reduced absorption of topical eye drops.

Cases of corneal calcification have been reported very rarely in association with the use of phosphate containing eye drops in some patients with significantly damaged corneas.

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