From the Guidelines
The risk of gastrointestinal (GI) bleeding with months of steroid therapy is significantly increased, particularly in patients with a history of GI bleeding or peptic disease, and these patients should be considered for gastroprotective medication such as proton pump inhibitors. According to the 2024 ESC guidelines for the management of chronic coronary syndromes 1, antithrombotic therapy may provoke GI bleeding, especially in patients at increased risk, including those with chronic use of steroids. The guidelines recommend gastric protection with proton pump inhibitors in patients at increased risk of GI bleeding for as long as any antithrombotic therapy is administered.
Some key factors that increase the risk of GI bleeding with steroid therapy include:
- High alcohol consumption
- Chronic use of non-steroidal anti-inflammatory drugs (NSAIDs)
- Receiving a combination of antithrombotic drugs
- History of GI bleeding or peptic disease
- Elderly patients
To minimize the risk of GI bleeding, patients taking steroids for months should consider the following:
- Gastroprotective medication such as a proton pump inhibitor (PPI) like omeprazole or esomeprazole
- Taking steroids with food to reduce gastric irritation
- Avoiding alcohol during the treatment period
- Immediately reporting any symptoms of GI bleeding such as black tarry stools, vomiting blood, or severe abdominal pain. The use of proton pump inhibitors has been shown to be effective in reducing the risk of GI bleeding, particularly from gastroduodenal lesions 1.
From the FDA Drug Label
Gastrointestinal Steroids should be used with caution in active or latent peptic ulcers, diverticulitis, fresh intestinal anastomoses, and nonspecific ulcerative colitis, since they may increase the risk of a perforation Signs of peritoneal irritation following gastrointestinal perforation in patients receiving corticosteroids may be minimal or absent.
The risk of Gastrointestinal (GI) bleeding with months of steroid therapy is increased, particularly in patients with active or latent peptic ulcers, diverticulitis, fresh intestinal anastomoses, and nonspecific ulcerative colitis, as steroids may increase the risk of perforation 2.
From the Research
Risk of Gastrointestinal (GI) Bleeding with Steroid Therapy
- The risk of GI bleeding with steroid therapy is a significant concern, as highlighted in several studies 3, 4, 5, 6, 7.
- A systematic review and meta-analysis found that corticosteroids increase the risk of GI bleeding or perforation by 40% (OR 1.43,95% CI 1.22 to 1.66) 5.
- The risk of GI bleeding was found to be higher in hospitalized patients (OR 1.42,95% CI 1.22 to 1.66) compared to those in ambulatory care (OR 1.63,95% CI 0.42 to 6.34) 5.
- Another study found that the combination of glucocorticoids and nonsteroidal anti-inflammatory drugs (NSAIDs) carries a high risk for GI bleeding (OR 20,95% CI 1.6-257) 6.
- The use of proton pump inhibitors (PPIs) as co-medication may help prevent GI bleeding in patients taking steroids or other medications that increase the risk of bleeding 7.
Factors Influencing the Risk of GI Bleeding
- The risk of GI bleeding is influenced by various factors, including the dose and duration of steroid therapy, the use of other medications such as NSAIDs or anticoagulants, and the presence of underlying medical conditions 4, 6, 7.
- A study found that increased daily and cumulative doses of corticosteroids were associated with increased excess risk of complications, including GI bleeding 4.
- The risk of GI bleeding was also found to be higher in patients with a history of peptic ulcer or those taking medications that increase the risk of bleeding, such as anticoagulants or platelet inhibitors 6, 7.
Clinical Implications
- Clinicians should be aware of the potential risk of GI bleeding associated with steroid therapy and take steps to minimize this risk, such as using the lowest effective dose and duration of therapy, and co-prescribing medications that can help prevent bleeding 4, 5, 7.
- Patients taking steroids or other medications that increase the risk of GI bleeding should be closely monitored for signs and symptoms of bleeding, and should seek medical attention immediately if they experience any unusual symptoms 6, 7.