What are the adverse effects of corticosteroids?

From the Guidelines

Steroids can cause numerous adverse effects when used, especially with long-term treatment or high doses, and should be used at the lowest effective dose for the shortest duration possible, with appropriate monitoring and tapering when discontinuing treatment. Common side effects include weight gain with characteristic fat redistribution (moon face, buffalo hump), increased appetite, fluid retention, hypertension, and hyperglycemia that may lead to diabetes 1. Steroids often cause mood changes including irritability, anxiety, euphoria, and even psychosis in some cases. They weaken the immune system, increasing susceptibility to infections. Long-term use leads to skin thinning, easy bruising, poor wound healing, acne, and hirsutism. Musculoskeletal effects include osteoporosis, increased fracture risk, and muscle weakness. Steroids can cause cataracts, glaucoma, and may suppress the hypothalamic-pituitary-adrenal axis, leading to adrenal insufficiency if stopped abruptly. They can also cause gastrointestinal issues like peptic ulcers, especially when combined with NSAIDs. These effects occur because steroids are powerful anti-inflammatory and immunosuppressive agents that affect multiple body systems by altering gene expression and cellular function.

Some of the key adverse effects of corticosteroids include:

• Weight gain and increased appetite
• Mood changes, such as irritability, anxiety, and euphoria
• Increased risk of infections
• Skin thinning, easy bruising, and poor wound healing
• Musculoskeletal effects, such as osteoporosis and muscle weakness
• Ophthalmologic effects, such as cataracts and glaucoma
• Gastrointestinal issues, such as peptic ulcers

The risk of these adverse effects can be minimized by using the lowest effective dose of steroids for the shortest duration possible, with appropriate monitoring and tapering when discontinuing treatment 1. It is also important to note that prolonged exposure to corticosteroids can trigger the onset of severe adverse events, such as weight gain, cataract, mood alterations, hypertension, and infections 1.

In terms of specific guidelines, it is recommended that initial corticosteroid treatment should be administered for no longer than 6-8 weeks, and excessively fast tapering should never be performed as it can lead to undesired effects 1. Additionally, patients who require on-demand administration of corticosteroids after completing first-line induction treatment should be considered as non-responders and should be promptly switched to alternative therapy 1.

Overall, while corticosteroids can be effective in treating various conditions, their use should be carefully considered and monitored due to the potential for numerous adverse effects.

From the FDA Drug Label

The following adverse reactions have been reported with prednisone or other corticosteroids: Allergic Reactions anaphylactoid or hypersensitivity reactions, anaphylaxis, angioedema Cardiovascular System bradycardia, cardiac arrest, cardiac arrhythmias, cardiac enlargement, circulatory collapse, congestive heart failure, ECG changes caused by potassium deficiency, edema, fat embolism, hypertension or aggravation of hypertension, hypertrophic cardiomyopathy in premature infants, myocardial rupture following recent myocardial infarction, necrotizing angiitis, pulmonary edema, syncope, tachycardia, thromboembolism, thrombophlebitis, vasculitis Dermatologic acne, acneiform eruptions, allergic dermatitis, alopecia, angioedema, angioneurotic edema, atrophy and thinning of skin, dry scaly skin, ecchymoses and petechiae (bruising), erythema, facial edema, hirsutism, impaired wound healing, increased sweating, Karposi’s sarcoma, lupus erythematosus-like lesions, perineal irritation, purpura, rash, striae, subcutaneous fat atrophy, suppression of reactions to skin tests, striae, telangiectasis, thin fragile skin, thinning scalp hair, urticaria Endocrine amenorrhea, postmenopausal bleeding or other menstrual irregularities, decreased carbohydrate and glucose tolerance, development of cushingoid state, diabetes mellitus (new onset or manifestations of latent), glycosuria, hyperglycemia, hypertrichosis, hyperthyroidism, hypothyroidism, increased requirements for insulin or oral hypoglycemic agents in diabetics, lipids abnormal, moon face, negative nitrogen balance caused by protein catabolism, secondary adrenocortical and pituitary unresponsiveness Fluid and Electrolyte Disturbances congestive heart failure in susceptible patients, fluid retention, hypokalemia, hypokalemic alkalosis, metabolic alkalosis, hypotension or shock-like reaction, potassium loss, sodium retention with resulting edema Gastrointestinal abdominal distention, abdominal pain, anorexia which may result in weight loss, constipation, diarrhea, elevation in serum liver enzyme levels (usually reversible upon discontinuation), gastric irritation, hepatomegaly, increased appetite and weight gain, nausea, oropharyngeal candidiasis, pancreatitis, peptic ulcer with possible perforation and hemorrhage, perforation of the small and large intestine, ulcerative esophagitis, vomiting Hematologic anemia, neutropenia (including febrile neutropenia) Metabolic negative nitrogen balance due to protein catabolism Musculoskeletal arthralgias, aseptic necrosis of femoral and humeral heads, increase risk of fracture, loss of muscle mass, muscle weakness, myalgias, osteopenia, osteoporosis, pathologic fracture of long bones, steroid myopathy, tendon rupture (particularly of the Achilles tendon), vertebral compression fractures Neurologic convulsions, delirium, dementia, depression, dizziness, EEG abnormalities, emotional instability and irritability, euphoria, hallucinations, headache, impaired cognition, incidence of severe psychiatric symptoms, increased intracranial pressure with papilledema, increased motor activity, insomnia, ischemic neuropathy, long-term memory loss, mania, mood swings, neuritis, neuropathy, paresthesia, personality changes, psychiatric disorders including steroid psychoses or aggravation of preexisting psychiatric conditions, restlessness, schizophrenia, verbal memory loss, vertigo, withdrawn behavior Ophthalmic blurred vision, cataracts (including posterior subcapsular cataracts), central serous chorioretinopathy, establishment of secondary bacterial, fungal and viral infections, exophthalmos, glaucoma, increased intraocular pressure, optic nerve damage, papilledema Other abnormal fat deposits, aggravation/masking of infections, decreased resistance to infection, hiccups, immunosuppression, increased or decreased motility and number of spermatozoa, malaise, moon face, pyrexia

The adverse effects of corticosteroids include:

• Allergic reactions: anaphylactoid or hypersensitivity reactions, anaphylaxis, angioedema
• Cardiovascular effects: bradycardia, cardiac arrest, cardiac arrhythmias, cardiac enlargement, circulatory collapse, congestive heart failure
• Dermatologic effects: acne, acneiform eruptions, allergic dermatitis, alopecia, angioedema
• Endocrine effects: amenorrhea, postmenopausal bleeding or other menstrual irregularities, decreased carbohydrate and glucose tolerance
• Fluid and electrolyte disturbances: congestive heart failure in susceptible patients, fluid retention, hypokalemia
• Gastrointestinal effects: abdominal distention, abdominal pain, anorexia, constipation, diarrhea
• Hematologic effects: anemia, neutropenia (including febrile neutropenia)
• Metabolic effects: negative nitrogen balance due to protein catabolism
• Musculoskeletal effects: arthralgias, aseptic necrosis of femoral and humeral heads, increase risk of fracture
• Neurologic effects: convulsions, delirium, dementia, depression, dizziness
• Ophthalmic effects: blurred vision, cataracts (including posterior subcapsular cataracts), central serous chorioretinopathy
• Other effects: abnormal fat deposits, aggravation/masking of infections, decreased resistance to infection, hiccups, immunosuppression 2

From the Research

Adverse Effects of Corticosteroids

The use of corticosteroids has been associated with several adverse effects, including:

• Osteoporosis: Long-term use of corticosteroids can increase the risk of osteoporosis, particularly in patients with asthma 3, 4, 5, 6
• Bone fractures: Corticosteroid use has been linked to an increased risk of bone fractures, especially in patients with asthma 5, 6
• Diabetes: There is evidence to suggest that corticosteroid use may increase the risk of diabetes 4, 5
• Ocular disorders: Corticosteroids have been associated with an increased risk of ocular disorders, such as glaucoma and cataracts 4, 5, 7
• Respiratory infections: Inhaled corticosteroid use has been linked to an increased risk of respiratory infections, including pneumonia and mycobacterial infections 5
• Hypothalamic-pituitary-adrenal (HPA) axis suppression: Corticosteroid use can suppress the HPA axis, leading to a range of systemic effects 4, 7

Factors Contributing to Adverse Effects

Several factors can contribute to the adverse effects of corticosteroids, including:

• Dose and duration of use: Higher doses and longer durations of corticosteroid use are associated with a greater risk of adverse effects 4, 5, 7, 6
• Type of corticosteroid: Inhaled corticosteroids (ICS) may have a lower risk of adverse effects compared to oral corticosteroids (OCS) 5, 6
• Individual susceptibility: Some individuals may be more susceptible to the adverse effects of corticosteroids, particularly those with a family history of glaucoma or other conditions 7