What are the effects of steroid toxicity?

From the Guidelines

Steroid toxicity can have severe and long-lasting effects on patients, and it is crucial to monitor and manage these effects carefully to minimize harm, as highlighted in the 2021 ASCO guideline update 1.

Key Considerations

• Patients on long-term corticosteroid therapy should undergo regular clinical and laboratory assessments to detect potential toxicities early.
• The lowest possible dose of steroids should be used for the shortest possible duration to minimize the risk of steroid-related toxicities, as emphasized in the 2021 study 1.
• Certain patient populations, such as those with pre-existing conditions like diabetes mellitus or an immune-compromised status, and the elderly, require special attention and careful monitoring due to their increased vulnerability to steroid toxicity.

Monitoring and Management

• Regular blood pressure checks, weight monitoring, and screening for symptoms of hyperglycemia, mood changes, sleep disturbances, and muscle weakness are essential for patients on long-term corticosteroid therapy.
• Laboratory evaluation should include fasting glucose or HbA1c every 3-6 months, electrolytes, and lipid profiles annually, as well as bone mineral density testing at baseline and every 1-2 years for patients on prolonged therapy.
• For patients on high-dose steroids (>20mg prednisone daily), more frequent monitoring of glucose levels and blood pressure is warranted, and ophthalmologic evaluation for cataracts and glaucoma should be performed annually.
• Adrenal function testing may be necessary when tapering steroids after prolonged use, and alternative therapies or preventive measures like calcium/vitamin D supplementation for bone health or proton pump inhibitors for gastrointestinal protection should be considered.

Prevention and Mitigation

• The use of prophylactic agents to prevent certain opportunistic infections and preemptive measures to mitigate various toxicities is necessary for patients needing longer-term steroid use, as recommended in the 2021 ASCO guideline update 1.
• A multidisciplinary approach may be used in the management of certain steroid-related complications, and institutional guidelines should be considered in decision-making.
• The combination regimen with azathioprine is associated with a lower occurrence of corticosteroid-related adverse events, and switching to budesonide or applying higher doses of azathioprine may be considered in patients presenting with steroid side effects, as suggested in the 2015 EASL clinical practice guidelines 1.

From the FDA Drug Label

The following adverse reactions have been reported with prednisone or other corticosteroids: Allergic Reactions anaphylactoid or hypersensitivity reactions, anaphylaxis, angioedema Cardiovascular System bradycardia, cardiac arrest, cardiac arrhythmias, cardiac enlargement, circulatory collapse, congestive heart failure, ECG changes caused by potassium deficiency, edema, fat embolism, hypertension or aggravation of hypertension, hypertrophic cardiomyopathy in premature infants, myocardial rupture following recent myocardial infarction, necrotizing angiitis, pulmonary edema, syncope, tachycardia, thromboembolism, thrombophlebitis, vasculitis Dermatologic acne, acneiform eruptions, allergic dermatitis, alopecia, angioedema, angioneurotic edema, atrophy and thinning of skin, dry scaly skin, ecchymoses and petechiae (bruising), erythema, facial edema, hirsutism, impaired wound healing, increased sweating, Karposi’s sarcoma, lupus erythematosus-like lesions, perineal irritation, purpura, rash, striae, subcutaneous fat atrophy, suppression of reactions to skin tests, striae, telangiectasis, thin fragile skin, thinning scalp hair, urticaria Musculoskeletal arthralgias, aseptic necrosis of femoral and humeral heads, increase risk of fracture, loss of muscle mass, muscle weakness, myalgias, osteopenia, osteoporosis, pathologic fracture of long bones, steroid myopathy, tendon rupture (particularly of the Achilles tendon), vertebral compression fractures Neuro-Psychiatric convulsions, delirium, dementia, depression, dizziness, EEG abnormalities, emotional instability and irritability, euphoria, hallucinations, headache, impaired cognition, incidence of severe psychiatric symptoms, increased intracranial pressure with papilledema, increased motor activity, insomnia, ischemic neuropathy, long-term memory loss, mania, mood swings, neuritis, neuropathy, paresthesia, personality changes, psychiatric disorders including steroid psychoses or aggravation of preexisting psychiatric conditions, restlessness, schizophrenia, verbal memory loss, vertigo, withdrawn behavior Ophthalmic blurred vision, cataracts, central serous chorioretinopathy, establishment of secondary bacterial, fungal and viral infections, exophthalmos, glaucoma, increased intraocular pressure, optic nerve damage, papilledema

The effects of steroid toxicity include:

• Allergic reactions: anaphylactoid or hypersensitivity reactions, anaphylaxis, angioedema
• Cardiovascular effects: bradycardia, cardiac arrest, cardiac arrhythmias, cardiac enlargement, circulatory collapse, congestive heart failure
• Dermatologic effects: acne, acneiform eruptions, allergic dermatitis, alopecia, angioedema
• Musculoskeletal effects: arthralgias, aseptic necrosis of femoral and humeral heads, increase risk of fracture, loss of muscle mass, muscle weakness, myalgias, osteopenia, osteoporosis
• Neuro-Psychiatric effects: convulsions, delirium, dementia, depression, dizziness, EEG abnormalities, emotional instability and irritability, euphoria, hallucinations, headache
• Ophthalmic effects: blurred vision, cataracts, central serous chorioretinopathy, establishment of secondary bacterial, fungal and viral infections, exophthalmos, glaucoma, increased intraocular pressure, optic nerve damage, papilledema 2, 2, 2

From the Research

Effects of Steroid Toxicity

The effects of steroid toxicity can be severe and varied. Some of the common effects include:

• Bone marrow depression, hemorrhagic cystitis, hair loss, infertility, and oncogenesis, as reported in a study on the treatment of nephrotic syndrome 3
• Psychosis, including hallucinations and delusions, as seen in a case report of a 12-year-old patient with discoid-type lupus erythematosus 4
• Weight gain, osteoporosis, cataracts, hypertension, diabetes mellitus, dyspepsia, and psychiatric complaints, as detected in an audit of patients on long-term oral corticosteroids 5
• Exacerbation of preexisting conditions or presentation of new medical conditions, as noted in a review of the pharmacology and complications of steroids 6
• Neuropsychiatric toxicity, including insomnia, cognitive impairment, mood symptoms, mania, psychosis, and severe depression, as reported in a systematic review of steroid-induced mental disorders in cancer patients 7

Specific Effects on Different Populations

The effects of steroid toxicity can vary depending on the population being treated. For example:

• In children, steroid-induced psychosis is a rare but serious adverse side effect, as reported in a systematic review of the literature 4
• In patients with cancer, steroid-induced mental disorders can be a significant complication of treatment, as noted in a systematic review of the current evidence 7
• In patients on long-term oral corticosteroids, monitoring for adverse effects is crucial to prevent and detect potential complications, as emphasized in a study on monitoring long-term oral corticosteroids 5

Common Adverse Effects

Some of the common adverse effects of steroid toxicity include:

• Weight gain, as reported in a study on monitoring long-term oral corticosteroids 5
• Osteoporosis, as detected in an audit of patients on long-term oral corticosteroids 5
• Cataracts, as reported in a study on monitoring long-term oral corticosteroids 5
• Hypertension, as noted in a review of the pharmacology and complications of steroids 6
• Diabetes mellitus, as detected in an audit of patients on long-term oral corticosteroids 5