What are the consequences and warnings to consider when starting a patient on chronic oral corticosteroids (steroids)?

Consequences and Warnings When Starting Chronic Oral Steroids

Patients starting chronic oral corticosteroids must be monitored for multiple serious complications including osteoporosis, adrenal suppression, metabolic disturbances, cardiovascular effects, and increased infection risk, with preventive measures implemented from the outset of therapy. 1, 2

Bone Health Complications

• Osteoporosis risk:

  • Fracture risk increases within 3 months of starting therapy 2
  • Higher doses (≥7.5 mg prednisone daily) significantly increase fracture risk 2, 3
  • Patients ≥40 years at higher risk than younger patients 2
  • Vertebral compression fractures occur in up to 27% of patients on long-term therapy 3

• Prevention measures:

  • Calcium supplementation (800-1000 mg daily) and vitamin D (800 IU daily) for all patients 2, 1
  • Baseline bone mineral density testing before or within 1 month of starting therapy 2
  • Bisphosphonate therapy for high-risk patients (T-score ≤-1.5 or FRAX 10-year risk ≥20% for major osteoporotic fracture) 2, 1
  • Follow-up bone density testing at 1 year, then every 2-3 years if stable, or annually if declining 2

Endocrine and Metabolic Effects

• Adrenal suppression:

  • Occurs in approximately 50% of patients after withdrawal of medium/high-dose therapy 2
  • Presents with weakness, fatigue, nausea, vomiting, and pain that can mimic underlying disease 2
  • Requires tapering when discontinuing therapy to prevent withdrawal syndrome 2

• Metabolic disturbances:

  • Regular monitoring of blood glucose (brittle diabetes in 20% of patients) 3, 1
  • Monitor serum potassium (risk of hypokalemia) 2, 1
  • Monitor blood pressure (risk of hypertension) 2, 1
  • Weight gain and fat redistribution (truncal obesity, moon facies in 80% after 2 years) 3, 1

Cardiovascular Effects

• Increased risk of:
  • Atherosclerosis and aortic aneurysm, particularly with doses ≥7.5 mg daily 3
  • Fluid retention and edema 1, 4
  • Hypertension requiring monitoring 2, 1
  • Left ventricular free wall rupture risk after recent myocardial infarction 1

Infection Risk

• Increased susceptibility:

  • Suppressed immune system increases risk of bacterial, viral, fungal, and other infections 1
  • Masked signs of infection due to anti-inflammatory effects 1
  • Risk of reactivation of latent tuberculosis 1
  • Severe or fatal course of varicella and measles in non-immune patients 1

• Prevention measures:

  • Complete immunizations before starting therapy 2
  • Consider prophylactic co-trimoxazole for high-risk patients 2
  • Avoid exposure to chickenpox or measles; seek immediate medical attention if exposed 1

Ophthalmologic Complications

• Regular monitoring for:
  • Elevated intraocular pressure (monitor after 6 weeks of therapy) 1
  • Posterior subcapsular cataracts with prolonged use 3, 1
  • Regular eye examinations recommended 1

Dermatologic Effects

• Common skin changes:
  • Skin thinning, easy bruising, and striae in 80% of patients after 2 years 3
  • Acne and facial hirsutism 3

Neuropsychiatric Effects

• Mental health impacts:
  • Range from euphoria and insomnia to severe depression and psychosis 1
  • Mood disturbances, personality changes 1
  • Insomnia is common even with short-term treatment 4, 5

Special Populations

Pediatric Patients

• Monitor growth velocity (more sensitive indicator than HPA axis tests) 1
• Titrate to lowest effective dose to minimize growth effects 1
• Regular height and weight measurements 1

Elderly Patients

• Start at lower doses due to increased risk of adverse effects 1
• Higher risk of diabetes, fluid retention, and hypertension 1
• Consider comorbidities and drug interactions 1

Women of Childbearing Potential

• Use effective birth control if sexually active 2
• Some medications used to prevent steroid complications (e.g., bisphosphonates) have fetal risks 2

Practical Management Recommendations

1. Before starting therapy:

   • Complete immunizations and establish varicella immunity 2
   • Baseline bone mineral density testing 2
   • Assess cardiovascular risk factors 3
   • Screen for latent tuberculosis 1

2. During therapy:

   • Use lowest effective dose for shortest duration possible 3, 6
   • Regular monitoring of blood pressure, glucose, potassium 2, 1
   • Provide steroid card/alert for emergency situations 2
   • Consider prophylactic medications for osteoporosis 2, 1

3. When discontinuing:

   • Always taper gradually to prevent adrenal insufficiency 2, 1
   • Monitor for withdrawal symptoms 2
   • Continue monitoring for complications even after discontinuation 3

Common Pitfalls to Avoid

• Abrupt discontinuation of therapy (can cause adrenal crisis) 1
• Failure to provide calcium and vitamin D supplementation 2, 1
• Inadequate monitoring of metabolic parameters 2, 1
• Overlooking increased infection risk and masking of infection signs 1
• Underestimating psychological effects 1
• Failure to consider drug interactions (e.g., with anticoagulants, antidiabetics) 1

By implementing these preventive measures and maintaining vigilant monitoring, the risks associated with chronic oral corticosteroid therapy can be minimized while maximizing therapeutic benefits.