A 55-year-old client with rheumatoid arthritis is being discharged on prednisone 20 mg PO every morning long term. Which discharge instruction is most important?

Long-term oral corticosteroids suppress the hypothalamic-pituitary-adrenal axis. Abrupt discontinuation causes adrenal insufficiency that can progress to adrenal crisis (hypotension, hypoglycemia, hyperkalemia, fatigue, vomiting, shock). Key teaching for chronic prednisone: (1) take with food in the morning to mimic the natural cortisol peak and reduce GI upset, (2) never stop abruptly; follow the prescribed taper, (3) report signs of infection (fever, sore throat, dysuria) because steroids mask classic signs and impair healing, (4) self-monitor for hyperglycemia, weight gain or edema, mood and sleep changes, easy bruising, and cataracts and glaucoma, (5) calcium 1000 to 1200 mg and vitamin D 800 to 1000 units daily, weight-bearing exercise, and bone-density monitoring for osteoporosis prevention, (6) wear a medical alert bracelet that identifies steroid dependency, (7) carry a sick day plan and obtain a stress dose during major illness, surgery, or trauma, (8) do not double a missed dose; take the next scheduled dose. Stopping early or doubling doses are direct contraindications.

The single most life-threatening teaching point is the no-abrupt-stop rule because of HPA suppression. Pair it with the with-food-in-morning rule for absorption and circadian alignment.