Prednisone steals over nine critical nutrients from the body. This nutrient depletion is responsible for many prednisone side effects.
What is Nutrient Depletion?
Let’s start by breaking up the term Nutrient Depletion. First, what is a Nutrient?
- Nutrients, also called micronutrients, are vitamins or minerals that your body needs to eat to live.
- Common nutrients include calcium (mineral) and vitamin D (vitamin).
So what is Depletion? Depletion is the emptying of an important substance.
- When you drive, you deplete your gas tank of gasoline.
- When you spend money, you deplete your bank account.
- When a plant’s leaves turn yellow, the soil may have nutrient depletion of nitrogen.
When you take prednisone, your “account” or “tank” of calcium is depleted.
Without nutrients, deficiencies occur and people can suffer diseases like:
- Osteoporosis (lack of calcium)
- Rickets (lack of vitamin D)
- Pellagra (lack of niacin)
- Scurvy (lack of vitamin C).
Which Nutrients does Prednisone Deplete?
Nutrients Depleted by Prednisone, in order of most- to least-depleted:
- Vitamin D
- Folic acid
- Vitamin A
- Vitamin C
- Vitamin K
- Vitamin B6*
- Vitamin B12*
* = Depletion level based on emerging research
The Sources of Prednisone Nutrient Depletion Data:
According to the Natural Medicines Database (NMD), prednisone:
- “Moderately depletes” calcium, vitamin D, chromium, and magnesium.
- Causes “insignificant depletion” of zinc.
- May also deplete selenium and strontium, with a NMD rating of “insufficient evidence to rate.”
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.
Why Does Prednisone Nutrient Depletion Matter?
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.” Check out this chart showing just some of the many side effects that may be associated with nutrient deficiency.
Read more below for an explanation for each nutrient, how prednisone nutrient depletion can lead to prednisone side effects.
Suggested Read: The next article in this series, The 10 Nutrients You Need will help you focus your diet on the foods most likely to help you give back the nutrients depleted by prednisone.
A list of good food to eat while on prednisone is available as a cheat sheet. Get your Nutrients You Need cheat sheet!
How Does Prednisone Deplete Nutrients?
Prednisone affects many parts of the body in several ways which lead to nutrient depletion.
For example, with calcium, prednisone changes:
- Urine: the body rids itself of more of the nutrient than usual through urine, such as magnesium and chromium.
- Gut: absorption of a nutrient is blocked in the gut, such as calcium.
- Bones: broken down by prednisone, releasing calcium and magnesium.
- Muscles: broken down by prednisone, leading to less calcium being used.
- Hormones: higher or lower levels than usual, leading to less calcium use in bone building.
Prednisone causes other more complicated effects for other nutrients, which will be outlined and explained below. The nutrients will be explained in the order in which they are most affected by prednisone.
Prednisone’s effects on calcium is the most complicated. A loss of calcium may be associated with tooth decay, plus heart and blood pressure irregularities. The most important consequence of calcium loss from prednisone is osteoporosis, which happens in the following ways:
- First, prednisone affects the gut, blocking calcium being absorbed by food.
- Next, prednisone causes the kidneys to get rid of calcium in the urine.
- Prednisone decreases our “sex hormones” like estrogen and testosterone, which normally tell the body to build up bone.
- Finally, prednisone stops the cells in our body which build bone (osteoblasts) from building back that which was lost.
If you want to dive deep into the science, here’s a chart showing how it works:
Osteoporosis is the big problem when prednisone depletes calcium. Bone loss comes from:
- the cells which break down bones (osteoclasts) in overdrive, and
- fewer of the cells which normally build up bone (osteoblasts).
Bone loss may lead to osteoporosis.
How quickly can prednisone cause osteoporosis?
Prednisone causes the greatest loss of bone density within the first 3-6 months. A myth perpetuated on patient support groups is that osteoporosis is a side effect that only affects very long-term users of prednisone. For those taking it less than 2 weeks, osteoporosis is not much of a concern. But for those taking prednisone longer than 3 months, the doctors who prescribe prednisone the most, rheumatologists, recommend supplementing calcium and vitamin D.
According to new research, prednisone depletes vitamin D which also affects the balance of calcium in the body. Vitamin D helps improve calcium absorption, so whenever someone takes calcium, vitamin D should also be taken. Since prednisone affects calcium, vitamin D also needs to be supplemented alongside the depleted calcium. According to the CDC, “Vitamin D is essential for good bone health, and it may help with muscle strength and protecting against cancer and type 2 diabetes.” A Cochrane Review stated:
“We reviewed a total of 5 trials which included 742 patients. We found that after two years of treatment, the bone mineral density of the lumbar spine and forearm of patients taking calcium and vitamin D therapy improved more than patients who had no treatment. We found that calcium and vitamin D is effective at preventing and treating corticosteroid‐induced bone loss at the lumbar spine and forearm.”
English translation? The experts say that there is evidence that taking calcium and vitamin D works to prevent bone loss caused by prednisone.
Everyone on prednisone for more than 3 months should be taking calcium and vitamin D.
Prednisone can cause the body to remove chromium through the urine. Chromium is a metal mineral which our bodies use to keep blood sugar steady. One of the most common side effects of prednisone is hyperglycemia, or high blood sugar, and may be caused by chromium deficiency. High blood sugar can lead to diabetes and weight gain. The loss of chromium from prednisone may cause elevated blood sugar, cholesterol, and triglycerides, and increase the risk of diabetes. It is important for those taking prednisone to have enough chromium.
Using prednisone for a long time can lead to magnesium loss in urine. In our bodies, magnesium is related to bones, so when the body breaks down bones, the body gets rid of the magnesium. The loss of magnesium from prednisone may also lead to cardiovascular problems, asthma, osteoporosis, cramps and PMS symptoms in women. Magnesium may also help with keeping healthy blood sugar levels.
When a person takes doses over 2.5 mg of prednisone per day, the hormone system called the HPA axis (hypothalamic-pituitary-adrenal gland axis), or “adrenal system,” is hijacked. The HPA axis helps control zinc levels, so when someone takes prednisone, zinc levels can fall. According to the CDC, “Zinc is a mineral that promotes immunity, resistance to infection, and proper growth and development of the nervous system.” Zinc can help maintain strong bones and healthy mood.
Prednisone interferes with the normal balance of electrolytes (sodium, potassium, and other salts) in the body, causing too much potassium to be removed in the urine. The body makes up for the loss of potassium by keeping too much sodium, or “salt.” This can lead to swelling and water retention, also known as edema. High blood pressure is another complication and is found 4 times as often in people taking prednisone than not taking prednisone. The loss of potassium from prednisone may also cause irregular heartbeat (palpitations), muscle weakness, and fatigue.
While on prednisone, limit your sodium intake and try to eat foods high in potassium. MedlinePlus, a publication of the U.S. National Library of Medicine, stated the following about special dietary instructions for people taking prednisone:
“Your doctor may instruct you to follow a low-salt, high potassium, or high calcium diet. Your doctor may also prescribe or recommend a calcium or potassium supplement.”
Prednisone may cause a loss of folic acid, but the mechanism is not clear. According to Clinical Pharmacology, folic acid loss from prednisone may lead to glossitis, which is swelling of the tongue. Folic acid is important for keeping a good mood and a healthy heart. A loss of folic acid from prednisone may be associated with anemia or cardiovascular disease.
How prednisone lowers the amount of vitamin A in the blood is unclear. Rarely, prednisone use may cause symptoms of vitamin A deficiency. Many symptoms of vitamin A deficiency overlap with prednisone side effects, so these may be related:
- Dry skin
- Dry eyes
- Night blindness
- Infertility and trouble conceiving
- Delayed growth in children
- Throat and chest infections
- Poor wound healing
- Acne and breakouts
According to the CDC:
“Vitamin A is necessary to support healthy eyesight and immune system functions.”
Be careful not to take too much Vitamin A as it can become toxic.
Similar to Vitamin A, taking prednisone can decrease the amount of vitamin C in the blood. A study showed that “giving vitamin C may restore sensitivity to glucocorticoids” like prednisone in very sick people, which means vitamin C may help people taking prednisone. Since vitamin C is vital for a healthy immune system, the loss of vitamin C may be responsible for the lowered immune system (immunosuppression) that prednisone causes. In addition, low vitamin C from prednisone may also be related to side effects such as easy bruising and poor wound healing.
Vitamin K is vital for bones and clotting. Loss of vitamin K may cause bruising and bleeding problems. In addition, vitamin K loss might reduce bone strength and worsen the risk for osteoporosis.
Prednisone causes muscle loss. The main site of the body’s nitrogen storage is the muscles, so it makes sense that urine from prednisone patients shows a loss of nitrogen. Collagen, the latticework that holds together much of our bodies, is made of nitrogen and amino acids. Collagen loss leads to muscle loss, bone loss, plus thinning skin and stretch marks.
Prednisone mood changes may be associated with B vitamins like vitamin B6. Low vitamin B6 is associated with depression, sleep disturbance, and increased cardiovascular disease risk. In addition, low B6 may cause confusion and a weak immune system.
Keep reading below to find out what you can do about this…
Is prednisone making you miserable, too?
Dr. Megan created a supplement designed especially for people taking prednisone.*
What else does prednisone change?
Melatonin, the hormone our bodies use for helping regulate our sleep-wake cycle, may be depleted by prednisone, according to new research.
Prednisone mimics our body’s natural stress hormone, cortisol, so its cycle is disrupted as well. Never stop taking prednisone suddenly, as your body needs time to fix this disruption and start making its own cortisol again. Always follow your doctor’s directions to slowly stop taking prednisone.
Does prednisone cause TOO MUCH of any nutrient?
Yes! Prednisone also tells the body to hold onto too much sodium, or salt. The section on “Potassium” above explains more.
What can I do about prednisone nutrient depletion?
The Experts: The American College of Rheumatology, the doctors who prescribe prednisone the most, created a guideline for people taking prednisone. They say:
All adults taking prednisone at a dose of greater than or equal to 2.5 mg per day for 3 months or more:
- Optimize calcium intake (1,000-1,200 mg/day) and
- Vitamin D intake (600-800 IU/day) and
- Lifestyle modifications (LM):
- balanced diet
- maintaining weight in the recommended range
- smoking cessation
- regular weight-bearing or resistance training exercise
- limiting alcohol intake to 1-2 alcoholic beverages per day
Eating a whole food diet with enough protein is vital for adequate nutrition while on prednisone. For more help, visit www.nutranize.com. -Dr. Megan
A registered dietitian emailed me to let me know exactly how he often sees these complications of prednisone treatment.
Want to learn more?
Read the next article in this series to understand which foods contain these vital nutrients. These 10 Nutrients You Need will help you focus your diet on the foods most likely to help you give back the nutrients depleted by prednisone. You can even watch a video explanation if you prefer to watch instead of read!
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