From the Guidelines
Steroid toxicity is a significant concern in patients taking corticosteroid medications, with adverse effects including weight gain, fluid retention, hypertension, hyperglycemia, mood changes, insomnia, increased susceptibility to infections, osteoporosis, adrenal suppression, skin thinning, and cataracts, and healthcare providers should prioritize minimizing steroid toxicity by prescribing the lowest effective dose for the shortest duration possible 1.
Effects of Steroid Toxicity
The effects of steroid toxicity can be severe and long-lasting, impacting various aspects of a patient's health and quality of life. Some common manifestations of steroid toxicity include:
- Weight gain and fluid retention
- Hypertension and hyperglycemia
- Mood changes, insomnia, and increased susceptibility to infections
- Osteoporosis, adrenal suppression, skin thinning, and cataracts
Minimizing Steroid Toxicity
To minimize steroid toxicity, healthcare providers should:
- Prescribe the lowest effective dose for the shortest duration possible
- Consider bone-protective agents like calcium, vitamin D supplements, or bisphosphonates for patients requiring long-term steroid therapy
- Gradually taper steroids rather than abruptly discontinuing them to prevent adrenal crisis
- Regularly monitor blood pressure, blood glucose, bone density, and eye examinations in patients on prolonged steroid therapy
Recent Guidelines and Recommendations
Recent guidelines and recommendations, such as those from the Delphi consensus recommendations for a treatment algorithm in pulmonary sarcoidosis, emphasize the importance of minimizing steroid toxicity and considering steroid-sparing alternatives 1. These guidelines recommend using the lowest effective dose of corticosteroids and considering alternative treatments, such as methotrexate or biologic agents, to reduce the risk of steroid toxicity and improve patient outcomes.
From the FDA Drug Label
Cardio-renal Caution is required in patients with systemic sclerosis because an increased incidence of scleroderma renal crisis has been observed with corticosteroids, including methylprednisolone As sodium retention with resultant edema and potassium loss may occur in patients receiving corticosteroids, these agents should be used with caution in patients with congestive heart failure or renal insufficiency. Musculoskeletal Corticosteroids decrease bone formation and increase bone resorption both through their effect on calcium regulation (e.g., decreasing absorption and increasing excretion) and inhibition of osteoblast function. Neuro-psychiatric An acute myopathy has been observed with the use of high doses of corticosteroids, most often occurring in patients with disorders of neuromuscular transmission (e.g., myasthenia gravis), or in patients receiving concomitant therapy with neuromuscular blocking drugs (e.g., pancuronium). Psychic derangements may appear when corticosteroids are used, ranging from euphoria, insomnia, mood swings, personality changes, and severe depression to frank psychotic manifestations.
The effects of steroid toxicity (corticosteroid toxicity) include:
- Cardio-renal effects such as increased incidence of scleroderma renal crisis, sodium retention, edema, and potassium loss
- Musculoskeletal effects such as decreased bone formation, increased bone resorption, and inhibition of osteoblast function, which may lead to osteoporosis
- Neuro-psychiatric effects such as acute myopathy, and psychic derangements including euphoria, insomnia, mood swings, personality changes, and severe depression
- Other effects include immunosuppression, increased risk of infection, and adrenal insufficiency 2, 2, 3
From the Research
Effects of Steroid Toxicity
The effects of steroid toxicity, also known as corticosteroid toxicity, can be significant and varied. Some of the key effects include:
- Adrenal insufficiency, which can be caused by chronic corticosteroid use 4, 5, 6, 7
- Suppression of the hypothalamic-pituitary-adrenal axis, leading to secondary adrenal insufficiency 5, 6, 7
- Cushing's syndrome and glucocorticoid withdrawal syndrome 5
- Reduced well-being and increased risk of adrenal crisis 6
- Clinically relevant side effects, such as exacerbation of preexisting conditions or presentation of new medical conditions 8
Risk Factors
Several factors can increase the risk of steroid toxicity, including:
- Duration of glucocorticoid therapy 5, 6
- Mode of administration 5
- Glucocorticoid dose and potency 5
- Concomitant drugs that interfere with glucocorticoid metabolism 5
- Individual susceptibility 5
Management and Treatment
Management and treatment of steroid toxicity typically involve:
- Gradual tapering of glucocorticoid therapy to avoid withdrawal syndrome 5
- Assessment of adrenal function recovery 5, 7
- Education on glucocorticoid-induced adrenal insufficiency for patients and providers 5
- Consideration of steroid-sparing treatments, such as biologic therapies, for conditions like severe asthma 6