What type of immune suppression do steroids cause?

From the Guidelines

Steroids cause moderate-severe immunosuppression with doses of ≥20 mg for >2 weeks. This type of immunosuppression is characterized by a significant reduction in the immune system's ability to fight off infections, making patients more susceptible to opportunistic infections, particularly fungal, viral, and certain bacterial infections 1. The degree of immunosuppression caused by steroids depends on the dose, duration, and route of administration, with higher doses and longer treatment durations resulting in more pronounced immunosuppressive effects.

Some key points to consider when evaluating the immunosuppressive effects of steroids include:

• The dose and duration of steroid treatment, with higher doses and longer treatment durations resulting in more significant immunosuppression
• The type of steroid used, with systemic steroids generally causing more significant immunosuppression than topical steroids
• The individual patient's underlying health status and risk factors for infection, such as age, comorbidities, and previous infections

According to the most recent and highest quality study, treatment with systemic steroids at doses of ≥20 mg for >2 weeks is considered moderate-severe immunosuppression, with a relative risk for infections of 1.85 compared to an RR of 1.10 for doses at <5 mg/day in patients >65 years 1. This highlights the importance of carefully weighing the benefits and risks of steroid treatment and taking steps to minimize the risk of infection, such as using prophylactic antimicrobial and antifungal agents, monitoring blood glucose levels, and providing supportive care measures 1.

In terms of specific steroid medications, common examples include prednisone, methylprednisolone, dexamethasone, and hydrocortisone, with their immunosuppressive effects being dose-dependent and typically more pronounced with higher doses and longer treatment durations 1. Overall, the immunosuppressive effects of steroids must be carefully considered and managed to minimize the risk of infection and ensure the best possible outcomes for patients.

From the FDA Drug Label

Corticosteroids may mask some signs of infection, and new infections may appear during their use There may be decreased resistance and inability to localize infection when corticosteroids are used. Children who are on immunosuppressant drugs are more susceptible to infections than healthy children Chickenpox and measles, for example, can have a more serious or even fatal course in children on immunosuppressant corticosteroids.

Steroids cause cell-mediated immune suppression, which can lead to:

• Decreased resistance to infection
• Inability to localize infection
• Increased susceptibility to infections, such as chickenpox and measles
• More serious or fatal course of infections in children on immunosuppressant corticosteroids 2 2

From the Research

Immune Suppression Caused by Steroids

Steroids can cause various types of immune suppression, including:

• Cell-mediated immunity suppression, which increases the susceptibility to intracellular infections 3
• Humoral immunity suppression, although this effect is marginal and predominantly restricted to cell-mediated immunity 4
• Suppression of T cells, including CD4+ and CD8+ T cells, which can occur early in the treatment with corticosteroids 5
• Suppression of B cells, which can be reversible but may persist even after cessation of corticosteroid treatment 5
• Decrease in absolute lymphocyte count (ALC) and absolute CD3+ T cells, which can be observed during corticosteroid therapy 5

Effects on Immune System

The effects of steroids on the immune system can be summarized as follows:

• Corticosteroids can induce neutrophilic leukocytosis concomitant with lymphopenia and eosinopenia, leading to immunosuppression 5
• T cell subsets and proliferation are susceptible to corticosteroids more than B cells, but the reversibility is faster with dose reduction in corticosteroids 5
• The change of B cells and B cell subtypes (CD27+ memory) shows a prolonged effect of corticosteroids on B cells, which may alter antibody production even after cessation of corticosteroid treatment 5
• Corticosteroids can affect the inflammatory response by way of vasoconstriction, decreased chemotaxis, and interference with macrophages 6