When is Prednisone Prescribed?

Prednisone is prescribed for a variety of conditions where inflammation or immune response needs to be controlled. It is commonly used for autoimmune disorders, such as rheumatoid arthritis, lupus, and multiple sclerosis, to reduce flare-ups and manage symptoms. In respiratory conditions like asthma and chronic obstructive pulmonary disease (COPD), Prednisone helps alleviate airway inflammation, making breathing easier. It is often used during acute exacerbations of these conditions. Allergic reactions, including severe skin rashes or anaphylaxis, can also be treated with Prednisone. By reducing the body’s allergic response, it provides rapid relief from symptoms. Prednisone is a critical medication for certain types of cancers, such as lymphoma and leukemia, where it helps suppress cancerous cell activity and manage associated inflammation. In dermatology, it is used to treat severe skin conditions like psoriasis and eczema by reducing skin inflammation and irritation. Additionally, it plays a role in organ transplant cases by preventing the immune system from rejecting the transplanted organ.

How Does Prednisone Help with Inflammatory Conditions?
Inflammatory conditions often involve excessive immune activity that damages tissues. Prednisone helps by dampening the immune system’s activity and reducing inflammation at the cellular level. For conditions like rheumatoid arthritis, Prednisone reduces joint swelling and pain, improving mobility and quality of life. It is often used in combination with disease-modifying drugs to achieve better results. In inflammatory bowel diseases such as Crohn’s disease and ulcerative colitis, Prednisone helps control abdominal pain, diarrhea, and bleeding by reducing gut inflammation. Asthma and COPD patients benefit from Prednisone’s ability to calm airway inflammation, leading to improved breathing and reduced risk of hospitalization during exacerbations. Prednisone also supports faster recovery in acute inflammatory conditions like severe allergies or infections by managing the body’s overreaction to triggers.

What Dosages of Prednisone Are Considered Effective?
Prednisone dosages vary widely depending on the condition being treated and the patient’s response. For mild to moderate inflammation, dosages typically range from 5 mg to 20 mg per day. Higher doses, such as 40 mg to 60 mg daily, may be used for severe conditions like lupus flares or asthma exacerbations. For acute conditions, short-term high-dose treatments, also known as "burst therapy," are common. These doses are gradually tapered to minimize side effects and avoid withdrawal symptoms. Chronic conditions may require lower maintenance doses to control symptoms over an extended period. Long-term use often necessitates regular monitoring to assess side effects and adjust dosages as needed. Pediatric dosages are calculated based on weight and severity of the condition, ensuring safety and effectiveness for younger patients. Specialized guidelines help determine appropriate doses in these cases. For critical conditions like organ rejection or severe allergic reactions, Prednisone may be administered in very high doses under close medical supervision to stabilize the patient rapidly.

What Should You Know About Taking Prednisone?
Prednisone is usually taken orally, with food or milk, to reduce the risk of stomach irritation. Patients are advised to take it at the same time daily to maintain consistent levels in the body. Tapering is essential when discontinuing Prednisone, especially after long-term use. Abruptly stopping the medication can lead to adrenal insufficiency, causing fatigue, low blood pressure, and other symptoms. Monitoring for side effects, such as weight gain, mood changes, and blood sugar fluctuations, is crucial during treatment. Regular check-ups help manage these risks effectively. Patients should avoid alcohol and consult their healthcare provider before using over-the-counter medications or supplements, as these can interact with Prednisone. Staying hydrated and maintaining a balanced diet can help mitigate side effects like fluid retention and increased appetite associated with Prednisone use.

What Are the Side Effects of Prednisone?
Prednisone, while effective, can cause a range of side effects, particularly with long-term use or high doses. Common side effects include increased appetite, weight gain, and fluid retention, which can lead to swelling in the hands and feet. Mood changes, such as irritability, anxiety, or depression, are also frequently reported, as Prednisone can affect brain chemistry. Sleep disturbances, including insomnia, are another common issue for patients taking this medication. Prolonged use of Prednisone can weaken bones, increasing the risk of osteoporosis and fractures. This is particularly concerning for older adults and those with pre-existing bone density issues. Prednisone may suppress the immune system, making patients more susceptible to infections. It can also elevate blood sugar levels, which is especially problematic for individuals with diabetes or those at risk of developing the condition. Other side effects include gastrointestinal issues, such as stomach pain or ulcers, and skin changes like thinning or easy bruising. Eye problems, including cataracts and increased intraocular pressure, may occur with extended use. Patients should be closely monitored for side effects during treatment, and any concerning symptoms should be addressed promptly to adjust the dosage or explore alternative therapies.

Alternative Treatments for Inflammation
For patients who cannot tolerate Prednisone or prefer non-steroidal options, alternative treatments for inflammation are available. Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen or naproxen, are commonly used for mild to moderate inflammatory conditions. Biologic therapies, including TNF inhibitors like adalimumab or infliximab, are effective for autoimmune diseases such as rheumatoid arthritis and Crohn’s disease. These targeted treatments work by directly interfering with specific inflammatory pathways. Natural anti-inflammatory supplements, such as omega-3 fatty acids, curcumin (found in turmeric), and ginger, may offer additional relief for some patients. These are often used in conjunction with other treatments. Physical therapy and lifestyle changes, including a balanced diet rich in anti-inflammatory foods and regular exercise, can significantly reduce inflammation in chronic conditions. Immunosuppressive drugs, such as methotrexate or azathioprine, are alternatives for managing autoimmune diseases when corticosteroids are not suitable. These medications suppress the immune response to reduce inflammation effectively. Ultimately, the choice of treatment depends on the underlying condition, patient preferences, and tolerance to different therapies. A personalized approach often yields the best results in managing inflammation.

Pharmacodynamics:
Prednisone is a synthetic glucocorticoid drug, a dehydrated analogue of hydrocortisone. It has anti-inflammatory, antiallergic, desensitizing, anti-shock, antitoxic and immunosuppressive effects. Interacts with specific cytoplasmic receptors and forms a complex that penetrates the cell nucleus, stimulates the synthesis of matrix ribonucleic acid (mRNA); the latter induces the formation of proteins, including lipocortin, mediating cellular effects. Lipocortin inhibits phospholipase A2, suppresses the release of arachidonic acid and suppresses the synthesis of prostaglandins, leukotrienes, which contribute to inflammation, allergy, etc. Suppresses the release of adrenocorticotropic hormone by the pituitary gland and secondarily - the synthesis of endogenous glucocorticosteroids. Inhibits the secretion of thyroid-stimulating and follicle-stimulating hormones. Reduces the number of lymphocytes and eosinophils, increases the number of erythrocytes (stimulates the production of erythropoietins). Protein metabolism: reduces the amount of protein in plasma (due to globulins) with an increase in the albumin/globulin ratio, increases the synthesis of albumins in the liver and kidneys; enhances protein catabolism in muscle tissue. Lipid metabolism: increases the synthesis of higher fatty acids and triglycerides, redistributes fat (fat accumulation mainly in the shoulder girdle, face, abdomen), leads to the development of hypercholesterolemia. Carbohydrate metabolism: increases the absorption of carbohydrates from the gastrointestinal tract; increases the activity of glucose-6-phosphatase, leading to an increase in the flow of glucose from the liver into the blood; increases the activity of phosphoenolpyruvate carboxykinase and the synthesis of aminotransferases; leading to activation of gluconeogenesis. Water-electrolyte metabolism: retains sodium and water in the body, stimulates the excretion of potassium (mineralocorticoid activity), reduces the absorption of calcium from the gastrointestinal tract, "washes out" calcium from the bones, increases its excretion by the kidneys. The anti-inflammatory effect is associated with the inhibition of the release of inflammatory mediators by eosinophils and mast cells, inducing the formation of lipocortin and reducing the number of mast cells that produce hyaluronic acid; with a decrease in capillary permeability, stabilization of cell membranes and organelle membranes (especially lysosomal). The antiallergic effect develops as a result of suppression of the synthesis and secretion of allergy mediators, inhibition of the release of histamine and other biologically active substances from sensitized mast cells and basophils, reduction in the number of circulating basophils, suppression of the development of lymphoid and connective tissue, reduction in the number of T- and B-lymphocytes, mast cells, reduction in the sensitivity of effector cells to allergy mediators, inhibition of antibody formation, and changes in the body's immune response. In obstructive respiratory diseases, the action is based mainly on inhibition of inflammatory processes, inhibition of the development or prevention of mucosal edema, inhibition of eosinophilic infiltration of the submucosal layer of the bronchial epithelium and deposition of circulating immune complexes in the bronchial mucosa. Inhibition of erosion and desquamation of the mucous membrane occurs. Prednisone increases the sensitivity of beta-adrenergic receptors of small and medium-sized bronchi to endogenous catecholamines and exogenous sympathomimetics, reduces the viscosity of mucus by inhibiting or reducing its production. Anti-shock and antitoxic effects are associated with an increase in blood pressure (due to an increase in the concentration of circulating catecholamines and restoration of the sensitivity of adrenoreceptors to them, as well as vasoconstriction), a decrease in the permeability of the vascular wall, membrane-protective properties, and activation of liver enzymes involved in the metabolism of endo- and xenobiotics. The immunosuppressant effect is due to the inhibition of lymphocyte proliferation (especially T-lymphocytes), suppression of B-cell migration and interaction of T- and B-lymphocytes, inhibition of cytokine release (interleukin-1, interleukin-2; gamma interferon) from lymphocytes and macrophages and a decrease in antibody formation. Inhibits connective tissue reactions during the inflammatory process and reduces the possibility of scar tissue formation.

Pharmacokinetics:
Absorption is high, the maximum concentration in the blood after oral administration is achieved after 1-1.5 hours. In plasma, up to 90% of prednisone binds to proteins: transcortin (cortisol-binding globulin) and albumins. Metabolized in the liver, kidneys, small intestine, bronchi. Oxidized forms are glucuronidated or sulfated. Metabolites are inactive. The half-life is 2-4 hours. It is excreted in bile and urine by glomerular filtration and 80-90% is reabsorbed by the tubules. 20% is excreted by the kidneys unchanged.

Indications:
Endocrine disorders: primary and secondary adrenal insufficiency (including the condition after removal of the adrenal glands); congenital adrenal hyperplasia; subacute thyroiditis.
Systemic connective tissue diseases: rheumatoid arthritis; systemic lupus erythematosus; dermatomyositis; scleroderma; periarteritis nodosa. Rheumatic fever, acute rheumatic carditis. Acute and chronic inflammatory diseases of the joints: scapulohumeral periarthritis; ankylosing spondylitis (Bechterew's disease); gouty and psoriatic arthritis; osteoarthritis (including post-traumatic); polyarthritis; juvenile arthritis, Still's syndrome in adults; bursitis; nonspecific tenosynovitis; synovitis; epicondylitis. Acute and chronic allergic diseases: allergic reactions to drugs and foods; drug exanthema; serum sickness; urticaria; hay fever; angioedema; allergic rhinitis.
Bronchial asthma, asthmatic status. Diseases of the blood and hematopoietic system: autoimmune hemolytic anemia; acute lympho- and myeloid leukemia; lymphogranulomatosis, thrombocytopenic purpura; agranulocytosis; panmyelopathy; secondary thrombocytopenia in adults; erythroblastopenia (erythrocyte anemia); congenital (erythroid) hypoplastic anemia. Skin diseases: pemphigus; eczema, psoriasis, exfoliative dermatitis; atopic dermatitis; diffuse neurodermatitis; contact dermatitis (with damage to a large surface of the skin); toxicoderma; seborrheic dermatitis; toxic epidermal necrolysis (Lyell's syndrome); bullous herpetiform dermatitis; malignant exudative erythema (Stevens-Johnson syndrome). Allergic and inflammatory eye diseases: allergic corneal ulcers; allergic forms of conjunctivitis; sympathetic ophthalmia; severe sluggish anterior and posterior uveitis; optic neuritis.
Gastrointestinal tract diseases: ulcerative colitis, Crohn's disease; hepatitis; local enteritis. Lung cancer (in combination with cytostatic drugs). Myeloma.
Lung diseases: acute alveolitis, pulmonary fibrosis, stage II-III sarcoidosis.
Kidney diseases of autoimmune genesis (including acute glomerulonephritis), nephrotic syndrome. Tuberculosis meningitis, pulmonary tuberculosis. Aspiration pneumonia (in combination with specific chemotherapy).
Berylliosis, Loeffler syndrome (not amenable to other therapy).
Multiple sclerosis.
Cerebral edema (including against the background of a brain tumor or associated with surgery, radiation therapy or head injury) after preliminary parenteral use. Prevention of transplant rejection during organ transplantation.
Hypercalcemia against the background of oncological diseases. Nausea and vomiting during cytostatic therapy.

Contraindications:
The only contraindication for short-term use for vital indications is hypersensitivity to prednisone or the components of the drug. In children during the growth period, glucocorticosteroids should be used only for absolute indications and under especially careful supervision of the attending physician.

With caution:
Prednisone should be prescribed with caution in the following conditions and diseases:
Parasitic and infectious diseases of viral, fungal or bacterial origin (currently or recently transferred, including recent contact with a patient): simple herpes, herpes zoster (viremic phase), chickenpox, measles; amebiasis, strongyloidiasis; systemic mycosis; active and latent tuberculosis. Use in severe infectious diseases is only allowed against the background of specific therapy.
Pre- and post-vaccination periods (a period lasting 8 weeks before and 2 weeks after vaccination), lymphadenitis after BCG vaccination.
Immunodeficiency states (including AIDS or HIV infection).
Diseases of the gastrointestinal tract: gastric ulcer and duodenal ulcer, esophagitis, gastritis, acute or latent peptic ulcer, recently formed intestinal anastomosis, ulcerative colitis with the risk of perforation or abscess formation, diverticulitis.
Diseases of the cardiovascular system, incl. recent myocardial infarction (in patients with acute and subacute myocardial infarction, the spread of the necrosis focus is possible, the formation of scar tissue slows down and, as a consequence, the heart muscle ruptures), uncompensated chronic heart failure, arterial hypertension, hyperlipidemia.
Endocrine diseases: diabetes mellitus (including impaired carbohydrate tolerance), thyrotoxicosis, hypothyroidism, Itsenko-Cushing's disease, obesity (grades III-IV). Severe chronic renal and/or hepatic failure, nephrolithiasis.
Hypoalbuminemia and conditions predisposing to its occurrence.
Systemic osteoporosis, myasthenia gravis, acute psychosis, poliomyelitis (except for the form of bulbar encephalitis), open-angle and closed-angle glaucoma.

Pregnancy and lactation:
During pregnancy, prednisone may be used if the expected benefit to the mother outweighs the potential risk to the fetus.
In the first trimester of pregnancy, prednisone is used only for vital indications.
With long-term therapy during pregnancy, the possibility of fetal growth disorders cannot be ruled out. If used in the third trimester of pregnancy, there is a risk of adrenal cortex atrophy in the fetus, which may require replacement therapy in the newborn. Since glucocorticosteroids penetrate into breast milk, if it is necessary to use the drug during breastfeeding, it is recommended to stop breastfeeding.

Method of administration and dosage:
The dosage and duration of treatment are selected by the doctor individually depending on the indications and severity of the disease.
Usually, the daily dose is taken once or a double dose is taken every other day, in the morning, between 6 and 8 am.
A high daily dose can be divided into 2-4 doses, with a larger dose taken in the morning. Tablets should be taken during or immediately after meals, with a small amount of liquid.
In acute conditions and as replacement therapy for adults, an initial dose of 20-30 mg / day is prescribed, the maintenance dose is 5-10 mg / day. For some diseases (nephrotic syndrome, some rheumatic diseases), higher doses are prescribed. Treatment is discontinued slowly, gradually reducing the dose. If there is a history of psychosis, high doses are prescribed under strict medical supervision.
Doses for children: initial dose - 1-2 mg / kg / day in 4-6 doses, maintenance - 0.3-0.6 mg / kg / day. When prescribing, the daily secretory rhythm of glucocorticosteroids should be taken into account: most (or all) of the dose is prescribed in the morning.

Side effects:
The frequency of development and severity of side effects depend on the duration of use, the amount of the dose used and the ability to maintain the circadian rhythm of prednisone administration.
From the endocrine system: suppression of adrenal function, decreased glucose tolerance, "steroid" diabetes mellitus or manifestation of latent diabetes mellitus, Itsenko-Cushing's syndrome (moon face, pituitary obesity, hirsutism, increased blood pressure, dysmenorrhea, amenorrhea, myasthenia, striae), growth retardation and delayed sexual development in children. From the gastrointestinal tract: oral candidiasis, nausea, vomiting, pancreatitis, "steroid" gastric ulcer and duodenal ulcer, erosive esophagitis, bleeding and perforation of the gastrointestinal tract, increased or decreased appetite, flatulence, hiccups. In rare cases - increased activity of "liver" transaminases and alkaline phosphatase. From the cardiovascular system: increased blood pressure, arrhythmia, bradycardia; development (in predisposed patients) or increased severity of chronic heart failure, ECG changes characteristic of hypokalemia, hypercoagulation, thrombosis. In patients with acute and subacute myocardial infarction - the spread of the necrosis focus, slowing down the formation of scar tissue, which can lead to rupture of the heart muscle.
From the nervous system: delirium, disorientation, euphoria, hallucinations, manic-depressive psychosis, depression, paranoia, increased intracranial pressure, nervousness or anxiety, insomnia, dizziness, vertigo, pseudotumor cerebellum, headache, convulsions.
From the sensory organs: posterior subcapsular cataract, increased intraocular pressure with possible damage to the optic nerve, a tendency to develop secondary bacterial, fungal or viral eye infections, trophic changes in the cornea, exophthalmos.
From the metabolic system: hypocalcemia, weight gain, negative nitrogen balance (increased protein breakdown), increased sweating.
Side effects due to mineralocorticoid activity - fluid and sodium retention (peripheral edema), hypernatremia, hypokalemic syndrome (hypokalemia, arrhythmia, myalgia or muscle spasm, weakness and fatigue).
From the musculoskeletal system: slow growth and ossification processes in children (premature closure of epiphyseal growth zones), osteoporosis (very rare - pathological bone fractures, aseptic necrosis of the head of the humerus and femur), rupture of muscle tendons, "steroid" myopathy, decreased muscle mass (atrophy).
From the skin and mucous membranes: delayed wound healing, petechiae, ecchymosis, thinning of the skin, hyper- or hypopigmentation, acne, striae, a tendency to develop pyoderma and candidiasis.
Kidney and urinary tract diseases: frequent nighttime urination, urolithiasis due to increased excretion of calcium and phosphate.
Immune system diseases: generalized (skin rash, itching, anaphylactic shock) and local allergic reactions.
Other: development or exacerbation of infections (the appearance of this side effect is facilitated by the combined use of immunosuppressants and vaccination), leukocyturia.

Overdose:
May increase dose-dependent side effects. It is necessary to reduce the dose of prednisone. Treatment is symptomatic.

Interaction:
Phenobarbital, phenytoin, rifampicin, ephedrine, aminoglutethimide, aminophenazone (inducers of "liver" microsomal enzymes) reduce the therapeutic effect of glucocorticosteroid hormones.
It may be necessary to increase the dose of insulin and oral hypoglycemic drugs due to the weakening of the hypoglycemic effect.
Both strengthening and weakening of the anticoagulant effect is possible when taking indirect anticoagulants (dose adjustment is required).
Anticoagulants and thrombolytics - the risk of bleeding from ulcers in the gastrointestinal tract increases. Ethanol and nonsteroidal anti-inflammatory drugs (NSAIDs) - the risk of erosive and ulcerative lesions in the gastrointestinal tract and bleeding increases (in combination with NSAIDs in the treatment of arthritis, the dose of glucocorticosteroids may be reduced due to the summation of the therapeutic effect).
Acetylsalicylic acid - prednisone accelerates its excretion and reduces its concentration in the blood. After discontinuation of glucocorticosteroid drugs, the concentration of salicylates may increase and intoxication may develop; due to the ulcerogenic effect of salicylates, the risk of gastrointestinal bleeding and ulceration increases. Indomethacin - increases the risk of side effects of prednisone (indomethacin displaces prednisone from albumin bonds).
The risk of hypokalemia increases with the use of amphotericin B, diuretics, theophylline, cardiac glycosides.
Carboanhydrase inhibitors and "loop" diuretics can increase the risk of osteoporosis.
When taking estrogens and oral estrogen-containing contraceptives, the clearance of glucocorticosteroids decreases, the half-life is prolonged, and the therapeutic and toxic effects of prednisone are enhanced. Increases the hemotoxicity of methotrexate. Reduces the stimulating effect of somatropin on growth. Vitamin D - its effect on calcium absorption in the intestine decreases.
Praziquantel - its concentration decreases; M-anticholinergics (including antihistamines and tricyclic antidepressants) and nitrates - contribute to an increase in intraocular pressure;
Isoniazid and mexiletine - prednisone increases their metabolism (especially in "slow" acetylators), which leads to a decrease in their plasma concentrations. Adrenocorticotropic hormone enhances the effect of prednisone.
Ergocalciferol and parathyroid hormone prevent the development of osteopathy caused by prednisone. Cyclosporine and ketoconazole, by slowing down the metabolism of prednisone, can in some cases increase its toxicity.
Glucocorticosteroids reduce the hypotensive effect of antihypertensive drugs.
The simultaneous administration of androgens and steroid anabolic drugs with prednisone contributes to the development of peripheral edema and hirsutism, the appearance of acne.
Mitotane and other inhibitors of adrenal cortex function may necessitate an increase in the dose of prednisone.
When used simultaneously with live antiviral vaccines and against the background of other types of immunization, it increases the risk of activation of viruses and the development of infections. Immunosuppressants increase the risk of developing infections and lymphoma or other lymphoproliferative disorders associated with the Epstein-Barr virus.
Antipsychotics (neuroleptics) and azathioprine increase the risk of developing cataracts when prednisone is prescribed.
Concomitant administration of antacids reduces the absorption of prednisone.
When used simultaneously with antithyroid drugs, the clearance of prednisone decreases, and with thyroid hormones, it increases.

Special instructions:
Before starting treatment, the patient should be examined for possible contraindications. Clinical examination should include examination of the cardiovascular system, X-ray examination of the lungs, examination of the stomach and duodenum; urinary system, visual organ.
Before and during steroid therapy, it is necessary to monitor the general blood test, glucose concentration in the blood and urine, electrolytes in the plasma. During treatment with glucocorticosteroids, especially in high doses, vaccination is not recommended due to a decrease in its effectiveness.
Medium and high doses of glucocorticosteroids can cause an increase in blood pressure. In tuberculosis, the drug can be prescribed only in combination with anti-tuberculosis drugs.
In intercurrent infections, septic conditions, simultaneous antibiotic therapy is necessary. During long-term treatment with glucocorticosteroids, potassium should be prescribed to avoid hypokalemia.
In Addison's disease, the drug should not be taken simultaneously with barbiturates due to the risk of developing acute adrenal insufficiency (Addisonian crisis). Glucocorticosteroid hormones can cause growth retardation in children and adolescents. Prescribing the drug every other day usually allows you to avoid or minimize the likelihood of developing this side effect.
In old age, the frequency of adverse reactions increases. With sudden cancellation, especially in the case of high doses, a glucocorticosteroid withdrawal syndrome occurs: decreased appetite, nausea, lethargy, generalized musculoskeletal pain, asthenia. The likelihood of adrenal insufficiency as a result of taking the drug and the complications associated with it can be reduced by gradually discontinuing the drug. After discontinuing the drug, adrenal insufficiency can last for months, so any stressful situation during this period should be followed by resuming hormonal therapy. In hypothyroidism and liver cirrhosis, the effect of glucocorticosteroid hormones may be enhanced. Patients should be warned in advance that they and their relatives should avoid contact with patients with chickenpox, measles, and herpes. In cases where systemic treatment with glucocorticosteroids is being carried out or treatment with glucocorticosteroid drugs was carried out in the last 3 months, and the patient has not been vaccinated, specific immunoglobulins should be prescribed. Treatment with glucocorticosteroids requires medical supervision in diabetes mellitus (including family history), osteoporosis (risk is higher in the postmenopausal period), arterial hypertension, chronic psychotic reactions (glucocorticosteroid hormones can cause mental disorders and increase emotional instability), history of tuberculosis, glaucoma, steroid myopathy, gastric ulcer and duodenal ulcer, epilepsy, herpes simplex of the eye (risk of corneal perforation).
Due to the weak mineralocorticoid effect, prednisone is used with mineralocorticoids for replacement therapy in adrenal insufficiency. In patients with diabetes mellitus, blood glucose levels should be monitored and therapy should be adjusted if necessary.

Effect on the ability to drive transport. cf. and mech.: The drug may affect a person's ability to drive vehicles and engage in other potentially dangerous activities that require increased concentration and speed of psychomotor reactions, since the drug may cause dizziness and other side effects that may affect the listed abilities.

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