What are the risks associated with long-term use of prednisone (corticosteroid)?

From the Guidelines

Long-term use of prednisone is associated with significant risks, including increased susceptibility to infections, osteoporosis, myopathy, and cataracts.

Risks Associated with Long-term Prednisone Use

• Increased risk of serious infections: The TREAT registry found that prednisone therapy was associated with an overall increased risk of serious infections (hazard ratio, 1.57; 95% CI, 1.17–2.10; P = .002) 1.
• Osteoporosis: Long-term corticosteroid treatment can lead to bone disease, and patients should be monitored for bone mineral densitometry of the lumbar spine and hip 1.
• Myopathy: Prolonged steroid use is associated with numerous side effects, including myopathy 1.
• Cataracts: Adverse effects associated with long-term use of corticosteroids include cataracts 1.
• Increased mortality: There is evidence of increased mortality in patients on long-term steroids, with a study showing that prolonged steroid use carries greater mortality compared with patients starting anti-TNF therapy 1.
• Suppression of the hypothalamic-pituitary-adrenal axis: Prolonged steroid use can lead to suppression of the hypothalamic-pituitary-adrenal axis 1.
• Diabetes: Long-term corticosteroid treatment can increase the risk of developing diabetes 1.
• Weight gain and cardiovascular disease: Prolonged steroid use is associated with weight gain and cardiovascular disease 1.

Management of Long-term Prednisone Use

• Monitoring for bone disease: Patients on long-term corticosteroid treatment should be monitored for bone mineral densitometry of the lumbar spine and hip 1.
• Eye examinations: Patients receiving prednisone should undergo eye examinations for cataracts and glaucoma periodically during treatment 1.
• Dose reduction: Prednisone may be tapered down to an individual level sufficient to maintain a remission from 20 mg daily onward, reduction should be done by 5 mg every week until 10 mg/day are achieved and even further reduction by 2.5 mg/week have been considered up to 5 mg daily 1.

From the FDA Drug Label

The lowest possible dose of corticosteroids should be used to control the condition under treatment. When reduction in dosage is possible, the reduction should be gradual Since complications of treatment with glucocorticoids are dependent on the size of the dose and the duration of treatment, a risk/benefit decision must be made in each individual case as to dose and duration of treatment and as to whether daily or intermittent therapy should be used Corticosteroids decrease bone formation and increase bone resorption both through their effect on calcium regulation (i.e., decreasing absorption and increasing excretion) and inhibition of osteoblast function. This, together with a decrease in the protein matrix of the bone secondary to an increase in protein catabolism, and reduced sex hormone production, may lead to inhibition of bone growth in pediatric patients and the development of osteoporosis at any age Growth and development of infants and children on prolonged corticosteroid therapy should be carefully observed. Special consideration should be given to patients at increased risk of osteoporosis (e.g., postmenopausal women) before initiating corticosteroid therapy. Corticosteroids can produce reversible hypothalamic-pituitary adrenal (HPA) axis suppression with the potential for corticosteroid insufficiency after withdrawal of treatment. Adrenocortical insufficiency may result from too rapid withdrawal of corticosteroids and may be minimized by gradual reduction of dosage This type of relative insufficiency may persist for up to 12 months after discontinuation of therapy; therefore, in any situation of stress occurring during that period, hormone therapy should be reinstituted. Corticosteroids, including prednisone tablets, suppress the immune system and increase the risk of infection with any pathogen, including viral, bacterial, fungal, protozoan, or helminthic pathogens The rate of infectious complications increases with increasing corticosteroid dosages. Monitor for the development of infection and consider prednisone tablets withdrawal or dosage reduction as needed.

The risks associated with long-term use of prednisone (corticosteroid) include:

• Osteoporosis: long-term use can lead to inhibition of bone growth and development of osteoporosis
• Adrenocortical insufficiency: rapid withdrawal of corticosteroids can result in adrenocortical insufficiency, which can persist for up to 12 months after discontinuation of therapy
• Increased risk of infection: corticosteroids suppress the immune system, increasing the risk of infection with various pathogens
• Growth effects in pediatric patients: long-term use can decrease growth velocity in pediatric patients
• Other complications: such as hypertension, fluid retention, and diabetes mellitus, particularly in elderly patients 2, 2, 2.

From the Research

Risks Associated with Long-Term Use of Prednisone

The long-term use of prednisone, a corticosteroid, is associated with various risks and side effects. Some of the common risks include:

• Lipodystrophy, which is the most frequent adverse event, occurring in 63.0% of patients, and is considered the most distressing by patients 3
• Neuropsychiatric disorders, which occur in 52.5% of patients, and may necessitate hospitalization in severe cases 3
• Skin disorders, which are noted in 46.2% of patients, and are more frequent in women 3
• Muscle cramp and proximal muscle weakness, which are reported by 32.5% and 15% of patients, respectively 3
• Newly developed hypertension, which occurs in 8.7% of patients 3
• Menstrual disorders, which are reported by 39% of premenopausal women 3

Long-Term Side Effects

Long-term use of oral corticosteroids is associated with a variety of well-established toxic effects, including:

• Suppression of the hypothalamic-pituitary-adrenal axis 4
• Osteoporosis, aseptic joint necrosis, adrenal insufficiency, gastrointestinal, hepatic, and ophthalmologic effects, hyperlipidemia, growth suppression, and possible congenital malformations 5
• Infection risk, which is dose-dependent and increases with chronic steroid therapy 6

Safety Concerns

The safe and effective use of oral corticosteroids requires careful consideration of the potential risks and side effects. Alternate-day prednisone therapy has been shown to be effective and safe in some patients, with minimal suppression of the hypothalamic-pituitary-adrenal axis 4. However, long-term corticosteroid use can expose the body to significant side effects and long-term health concerns, making it essential to be aware of the risks and take steps to mitigate them 7.