Diagnosing Steroid Toxicity
The diagnosis of steroid toxicity requires a systematic evaluation of clinical manifestations and laboratory findings based on the affected organ systems, with immediate discontinuation or dose reduction of the steroid as the primary intervention for severe cases. 1
Clinical Manifestations by Organ System
Endocrine System
- Cushingoid features: Moon facies, buffalo hump, central obesity, striae
- Hyperglycemia: Monitor blood glucose levels regularly, especially in patients with pre-existing diabetes
- Hypothalamic-pituitary-adrenal axis suppression: Assess for symptoms of adrenal insufficiency during tapering or after discontinuation
Skin
- Skin thinning, easy bruising, acne, hirsutism
- Poor wound healing
- Striae formation (purple/red streaks on abdomen, thighs, breasts)
Musculoskeletal System
- Proximal muscle weakness (difficulty rising from sitting position)
- Osteoporosis: Consider bone density testing for long-term users
- Avascular necrosis of joints, particularly the femoral head
Cardiovascular System
- Hypertension: Regular blood pressure monitoring
- Fluid retention and edema
- Electrolyte abnormalities, particularly hypokalemia
Neuropsychiatric
- Mood changes, euphoria, depression, psychosis
- Insomnia
- Cognitive changes
- Personality changes
Gastrointestinal
- Peptic ulcer disease (especially when combined with NSAIDs)
- Pancreatitis
- Fatty liver changes
Ocular
- Posterior subcapsular cataracts
- Glaucoma: Regular eye examinations recommended 2
Immune System
- Increased susceptibility to infections
- Reactivation of latent infections (tuberculosis, herpes)
Laboratory Investigations
First-line Testing
- Complete blood count
- Comprehensive metabolic panel (glucose, electrolytes, liver function)
- Lipid profile
- Morning cortisol level (to assess HPA axis function)
- Bone mineral density for long-term users
Additional Testing Based on Symptoms
- ACTH stimulation test (for suspected adrenal insufficiency)
- Ophthalmologic examination
- Dual-energy X-ray absorptiometry (DEXA) scan
Diagnostic Approach Algorithm
Assess exposure history:
- Duration of steroid therapy
- Dosage (higher doses increase risk)
- Type of steroid (oral vs. inhaled vs. topical)
- Pattern of use (continuous vs. intermittent)
Evaluate for high-risk factors:
- Advanced age
- Pre-existing diabetes
- Hypertension
- Osteoporosis
- Immunocompromised status 2
System-specific assessment:
- For neurological symptoms: Comprehensive neurological examination, consider MRI/MRA brain or spine, nerve conduction studies 1
- For hepatic toxicity: Liver function tests, consider ultrasound if abnormal
- For cardiac toxicity: ECG, echocardiogram if symptoms present
- For renal toxicity: Urinalysis, BUN/creatinine, GFR calculation
Grading severity:
- Mild: No interference with function
- Moderate: Some interference with activities of daily living
- Severe: Limits self-care, potentially life-threatening 1
Management Principles
For confirmed steroid toxicity:
- Mild toxicity: Consider dose reduction if possible
- Moderate toxicity: Withhold steroid if feasible, initiate prednisolone 0.5-1 mg/kg if symptoms are progressing 1
- Severe toxicity: Withhold steroid, hospitalize patient if necessary, initiate appropriate organ-specific management 1
Important Caveats and Pitfalls
- Adrenal crisis risk: Never abruptly discontinue steroids in long-term users without tapering
- Withdrawal symptoms: May mimic disease flare or steroid toxicity
- Drug interactions: Medications like phenytoin, phenobarbital, and rifampin can enhance steroid clearance, affecting toxicity risk 3
- Masking of infection: Steroids can suppress fever and inflammatory response, making infections harder to detect
- Misattribution: Symptoms may be incorrectly attributed to underlying disease rather than steroid toxicity
Special Considerations
- Pregnancy: Additional monitoring required due to potential fetal effects
- Children: Regular growth monitoring essential 2
- Elderly: More susceptible to adverse effects, particularly osteoporosis, hypertension, and diabetes
- Immunocompromised: Higher risk of opportunistic infections
By following this systematic approach to diagnosis, steroid toxicity can be identified early, allowing for appropriate intervention to minimize long-term complications.