Can Prednisone Cause Aches and Pains? – Prednisone Pain Paradox

Prednisone, a powerful medication with a dual nature, offers relief from a variety of medical conditions while simultaneously posing significant challenges due to its side effects. Let us delves into the complexities of this medication in this insightful article, “The Prednisone Pain Paradox.”

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How to Escape the Prednisone Pain Paradox

The prednisone pain paradox: how one drug can simultaneously help with more diseases than any other and cause more pain and side effects than any other drug. But there is hope, with new solutions to counteract prednisone side effects outlined in this article. Dr. James Howard, professor of neurology at the University of North Carolina Chapel Hill School of Medicine stated, “Prednisone is the most hated drug in the world.” Because of its many side effects, patients prescribed prednisone hate how it makes them feel.

Doctors prescribe prednisone for more varied conditions than any other drug. Prednisone not only helps with typical diseases like rheumatoid arthritis and asthma, but it also helps with off-label conditions that do not show up in the drug’s label, yet are guideline-directed for conditions like polymyalgia rheumatica. Prednisone can be prescribed for hundreds of inflammatory and autoimmune conditions and can be prescribed by any type of doctor from a rheumatologist to ophthalmologist, podiatrist to dentist.

Many of these conditions are painful in the traditional sense of causing pain receptors to send a signal of pain to the rest of the body. Others are less traditionally painful, but the need is so great that prednisone is prescribed. Prednisone is often a last-resort treatment, and patients have no treatment alternatives.

Prescribers consider that the benefit of treatment, which is often a goal for less pain, will outweigh the risks for side effects. The goal is probably a statement like this one from a prednisone patient, “After nearly a year of pain the miracle of pain relief within hours was a miracle. Six months on yes, I have weight gain and moon face and the odd aches and pains on tapering but hey I’ve got my life back.” In this patient’s case, the benefits outweigh the risks, but that is often not the case.

The side effects of prednisone may be severe and cause pain of their own. As Chancay, et al, stated, “A critical issue in the management of [rheumatoid arthritis] is recognition that not all pain in RA is due to active disease. Patients with RA also experience non-inflammatory pain which includes… side effects of treatment…” For many patients, the side effects do not outweigh the benefits. Perhaps prednisone is the most hated drug because it causes unbearable side effects, yet people cannot live without it, and too often, the side effects seem worse than the condition itself.

Prednisone Causes Pain

Prednisone side effects can affect nearly every part of the body, causing both physical pain and non-inflammatory pain. One prednisone patient said, “It hurts every part of your body. It also causes so many other diseases or problems.” In addition, many studies document the lower quality of life caused by glucocorticoid use (Costello, et al).

While prednisone can be lifesaving, it also creates its own type of misery. Prednisone can cause pain that is underappreciated by most prescribers. Prescribers may be aware of some of the common side effects of prednisone, but unaware of the many side effects that are inconsistently documented in typical drug information resources leading to gaps in information and gaps in care.

Prevalence of Prednisone Use and Adverse Drug Events

Approximately 0.5-1% of the United States population is taking prednisone long-term, many of whom are experiencing side effects. 80% of patients taking prednisone for myasthenia gravis report adverse events (Lee, et al). Use of prednisone and other glucocorticoids is associated with 10% of adverse drug events, making this class of drug the most common cause of adverse drug events in hospitals, yet the information about prednisone side effects is inconsistent and incomplete (Weiss et al). Unlike newly approved medications for which the U.S. Food and Drug Administration (FDA) requires a battery of tests to show which side effects are most common, prednisone is an old drug, approved in 1955, and no manufacturer was ever required to test for side effects. The FDA-certified drug label contains only a small selection of side effects and does not include some of the most common issues, such as “moon face” (Yardimci, et al).

A study of 604 patients and their perception of prednisone side effects showed that weight gain, insomnia, and moon face were the top three most important side effects to them (Costello, et al). When asked about their perception of the worst side effect from prednisone, weight gain, moon face, and mood changes topped the list for 97 vasculitis patients (Yardimci). Insomnia and weight gain are also the most commonly tweeted side effects of prednisone (Patel, et al). Yet none of these are listed in the FDA drug label under “Adverse Reactions.” The available information regarding adverse reactions does not correlate to the actual experience of prednisone patients. Many side effects are underappreciated by prescribers because the information is not available to the prescribers.

Prednisone Withdrawal Syndrome Pain

One example of a less-known side effect is prednisone withdrawal syndrome. Most physicians do not receive education about prednisone withdrawal syndrome and thus are not aware of the possibility of it happening nor how to identify it. The withdrawal from prednisone can be incredibly painful with manifestations from myalgia and arthralgia to diffuse headaches that do not respond to any known pain treatment. The fatigue, brain fog, and dizziness can be so profound that patients cannot leave their beds unassisted (Margolin, et al).

Complicating this is that prednisone withdrawal symptoms are nonspecific, so the withdrawal condition is often mistaken for other diseases, and a solution is not provided. People experiencing prednisone withdrawal symptoms may be mistakenly told they have a covid infection, long covid, fibromyalgia, or other differential diagnoses. Patients experiencing prednisone withdrawal syndrome can suffer for weeks to months without support because prescribers are unaware of its existence nor how to treat it.

Prednisone causes many types of bone issues

Osteoporosis can lead to both an increased risk for fracture and a loss of height, especially in the spine, which are sometimes painless, and these fractures may go unrecognized until a loss of height is documented. Yet other times the osteoporotic fractures cause intense pain. While glucocorticoid-induced osteoporosis is the most common type of bone side effect from prednisone, there are others. One prednisone patient stated that after 7.5 years of prednisone, “my muscles and bones ache daily.” Avascular necrosis is a very painful and destructive side effect that causes bone death and requires joint replacement, even in young patients who were previously healthy before taking prednisone.

Prednisone causes other types of pain

The prednisone withdrawal pain and osteoporosis are not the only type of pain that prednisone causes. Prednisone causes more side effects than possibly any other drug. While many of the side effects may not be traditional pain, they are painful in their own “non-inflammatory” way. The types of pain prednisone may also include emotional, psychological, and relationship pain.

Emotional prednisone pain

Prednisone causes personality changes that are shocking to people prescribed it. A prednisone patient said, “it can make you so unhappy that you want to die.” Another said, “The mood swings truly feel authentic, I’m not just blaming the pills, I literally can’t tell what’s real when I’m ‘roiding out.”

In addition, the physical side effects of prednisone are emotionally difficult to accept. The moon face, while seemingly not an issue to prescribers, is often described as the worst side effect to prednisone. “The worst part of illness has been the disfiguration of my face and body being on so much steroids for so long. And [my mother] was a bit unsympathetic. That I should get over it ‘cause they save my life. Yes, they have. And I’m grateful. But I’m not being vain. It’s just upsetting to look in the mirror and see another face. You can be grateful but also be sad at the same time.”

Prednisone weight gain happens to 70% of prednisone patients, and many struggle accepting their new change in appearance. Prednisone-induced weight gain can worsen the original condition for which prednisone was prescribed, such as types of arthritis, putting an even greater burden on joints already in pain.

Reflecting on prednisone side effects, one patient said, “I think the mental game for me is harder than the physical side effects. I know the medicine is saving my life. But the heart palpitations make me more anxious. The weight gain makes me depressed. The insomnia makes me so tired that I don’t feel like a strong person because I need naps. The physical toll it takes makes me feel weak.”

Psychological prednisone pain

One dose—just one pill—of prednisone or other steroids is enough to cause psychological changes to the prednisone patient (Bordag, Tacey, Judd). The anxiety and panic attacks that even a small dose can cause can be disabling and stunning in their intensity. Previously healthy people given a small prednisone prescription suddenly deal with panic attacks and crippling anxiety so much so that they cannot even tolerate watching TV or being near family members. After taking prednisone for a wasp sting, a prednisone patient stated, “I took 20mg of prednisone a few times—maybe 3 times total. Since then, I’ve been dealing with extreme anxiety and daily panic attacks. I’ve barely been able to go to work and take care of my kids.”

Relationship Pain

Patients on prednisone struggle with how the mood changes caused by the drug affect their relationships. Family members may not understand the personality and mood changes. Here are a few things prednisone patients wish their family knew about prednisone:

“My patience has been sucked dry by the prednisone and my anger is out of control because of the prednisone.”
“It’s a very lonely place. Nobody wants to bother. Depressing, insomnia, pain, hunger, feeling like you have no control over your life.”
“I wish they knew how hard it is to take The Devil’s Tic Tacs due to side effects…mentally and physically.”
“I truly believe it would be for them to know that my anger issues was the meds, not me just being hateful and angry person.”

Prednisone patients have asked to explain what it does so that family members affected by it will understand, instead of seeking separation, divorce, loss of parental rights, loss of jobs, and other consequences of the mind- and mood-altering qualities of prednisone.

Prednisone Patients’ Pain Can be Counteracted

The good news is that many of the side effects of prednisone can be explained and counteracted or even reversed. Prednisone is a pharmacological mimic of the endogenous hormone, cortisol, but given at supraphysiological doses. These high doses of cortisol-equivalent lead to many side effects. Cortisol exerts many of its effects by pausing long-term priorities, like bone density and reproduction, and emphasizing short-term priorities like survival from calamities, famine, war, or ill health. Consequently, cortisol plunders bone density and muscle mass to accomplish the short-term goal of surviving.

Cortisol uses up nutritional reserves in bone, muscle, and liver. It is this nutrient depletion that causes the side effects. Glucocorticoid-induced bone loss is associated with low calcium, vitamin D, and magnesium. Nutrient depletion causing side effects leads to the natural conclusion that replenishment of nutrients depleted will counteract or minimize side effects.

The doctors who prescribe prednisone the most, the rheumatologists, created a guideline based on this premise. The 2022 American College of Rheumatology (ACR) Guideline for the Prevention and Treatment of Glucocorticoid-Induced Osteoporosis recommends to “optimize dietary and supplemental calcium (1000-1200 mg/day) and vitamin D (600-800 IU/day)” as initial treatment for adults.

As a glucocorticoid, prednisone affects the metabolism in many ways, most predominantly the glucose-regulating systems, hence the drug class name, glucocorticoid. Glucocorticoids are the most common cause of drug-induced diabetes (Patt et al). A consequence of this dysregulation of glucose is an increase in chromium loss. A study by Ravina, et al stated, “Since steroid-induced diabetes was associated with increased chromium losses and insufficient dietary chromium is associated with glucose intolerance and diabetes, we treated three patients with steroid-induced diabetes with 600 microg per day of chromium as chromium picolinate. Chromium supplementation of patients with steroid-induced diabetes resulted in decreases in fasting blood glucose values from greater than 13.9 mmol/l (250 mg/dl) to less than 8.3 mmol/l (150 mg/dl). Hypoglycaemic drugs were also reduced 50% in all patients when given supplemental chromium.”

Chromium picolinate also can improve muscle mass, hunger cravings, significantly attenuate body weight gain and visceral fat accumulation. Prednisone can cause all those as side effects.

Prednisone-Induced Nutrient Depletion

Prednisone causes nutrient depletion of other nutrients besides those already listed above (calcium, vitamin D, and chromium). The following are nutrients listed in the order of most depleted with greater scientific sources showing prednisone-induced depletion: magnesium, zinc, potassium, folic acid, vitamin A, vitamin C, melatonin, vitamin K, nitrogen, phosphorus, vitamin B6, selenium, and vitamin B12.

A brief review of the available research published on prednisone-induced nutrient depletion follows.

According to the Natural Medicines Database (NMD), prednisone “moderately depletes” calcium, vitamin D, chromium, potassium, and magnesium. Prednisone causes “insignificant depletion” of zinc.

Clinical Pharmacology, the most complete drug information reference available today, shows that prednisone also depletes potassium, folic acid, and vitamins A and C.

Lexicomp, a trusted drug information database, states that prednisone patients “…may require increased dietary intake of pyridoxine (vitamin B6), vitamin C, vitamin D, folate (folic acid), calcium, and phosphorus. May require decreased dietary intake of sodium, and potassium supplementation.”

According to International Clinical Nutrition Review, oral corticosteroids have been shown to increase urinary loss of calcium, vitamin K, vitamin C, potassium, selenium, nitrogen, and zinc. Dr. Buist adds that corticosteroids cause decreased absorption of calcium and phosphorus.

The book by Pelton and LaValle, The Nutritional Cost of Prescription Drugs, shows that corticosteroids like prednisone deplete the following: calcium, vitamin D, potassium, magnesium, zinc, vitamin C, vitamin B6, vitamin B12, folic acid, selenium, and chromium.

The nutrients depleted by prednisone may directly lead to the most common side effects of prednisone. According to Pelton and LaValle, “Many of the side effects from drugs may actually be due to nutrient depletions that are caused by the drugs.”
Some of the side effects of prednisone that may be attributed to nutrient depletion include the following side effects and the related nutrients depleted:

Osteoporosis: calcium, vitamin D, vitamin K, magnesium, vitamin C, zinc
High blood sugar, diabetes, weight gain: chromium, vitamin C, calcium
Immune dysfunction: zinc, vitamins A, C, and D
Hypertension: potassium, calcium, folate
Poor wound healing: zinc, folate, B vitamins
Dyspepsia: magnesium, calcium, zinc
Insomnia: magnesium
Dyslipidemia: niacin, magnesium, chromium
Cataracts: riboflavin, thiamine, vitamin D
Depression and mood changes: zinc, B vitamins
Erythema: vitamin C

Understanding a potential cause for these intolerable side effects leads to the next logical step: replenishing the nutrients depleted. Patients on prednisone should eat a diet rich in these nutrients depleted. As in the ACR guideline, supplementation is often necessary to replenish the level of depletion caused by prednisone.

In addition to these nutrients that may directly cause side effects by their loss, other complementary therapies may ease or counteract prednisone side effects. The Natural Medicines Database (NMD) showed that these natural therapies may potentially help the following:

Berberine: diabetes, high blood glucose, hyperlipidemia, hypertension
Cassia cinnamon: diabetes
Melatonin: insomnia, anxiety, hypertension

A combination of these natural therapies with replenishment of the nutrients depleted would support people on prednisone. Many of the side effects could be minimized, leading to less pain among prednisone patients.

Prescribers and pharmacists should recommend replenishing the nutrients depleted, such as calcium, vitamin D, chromium, magnesium, and potassium, etc. to their prednisone patients. A supplement would be useful because it counterbalances the effects of prednisone in depleting nutrients or interfering with the metabolism of nutrients.

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