What is the correlation between steroid use and stroke risk?

Steroid Use and Stroke Risk

Anabolic steroids significantly increase stroke risk in young, otherwise healthy individuals, while therapeutic corticosteroids may increase stroke risk in specific conditions but are beneficial in treating certain stroke-causing conditions like vasculitis.

Anabolic-Androgenic Steroids and Stroke Risk

• Anabolic-androgenic steroids (AAS) have been linked to ischemic stroke in young, otherwise healthy individuals through multiple case reports 1, 2, 3, 4

• AAS can increase stroke risk through several mechanisms:

  • Increased vascular tone and arterial tension
  • Enhanced platelet aggregation
  • Creation of prothrombotic states
  • Alteration of lipid profiles (decreased HDL, increased LDL) 1

• Young athletes and bodybuilders using AAS for non-medical purposes are particularly at risk, with documented cases of stroke occurring in individuals as young as 26 and 34 years old 1, 2

Therapeutic Corticosteroids and Stroke Risk

Beneficial Effects in Certain Conditions

• In patients with ischemic stroke or TIA attributed to giant cell arteritis, immediate initiation of high-dose glucocorticoids is recommended to reduce recurrent stroke risk (Class 1, Level B-NR) 5

• For primary CNS angiitis, induction therapy with glucocorticoids followed by steroid-sparing immunosuppressants is reasonable to lower stroke recurrence risk (Class 2a, Level B-NR) 5

• Methotrexate or tocilizumab therapy adjunctive to steroids is reasonable in patients with giant cell arteritis to lower recurrent stroke risk (Class 2a, Level B-NR) 5

Potential Risks and Adverse Effects

• Long-term use of higher doses of glucocorticoids (≥5 mg of prednisone) in patients with rheumatoid arthritis is associated with higher risk of cardiovascular events 5

• Corticosteroids can cause:

  • Elevation of blood pressure
  • Salt and water retention
  • Increased potassium excretion
  • These effects may contribute to stroke risk 6, 7

• In acute cerebral infarction, a double-blind study showed that patients treated with dexamethasone fared slightly worse than those treated with placebo, with more deaths from cerebral edema in the steroid group 8

Testosterone Replacement Therapy and Stroke Risk

• In men 45 to 80 years of age with confirmed hypogonadism, testosterone replacement therapy is reasonable and does not increase stroke risk (Class 2a, Level B-R) 5

• The 2023 TRAVERSE study found no significant difference in the incidence of nonfatal stroke in men with hypogonadism receiving testosterone gel compared to placebo 5

Clinical Recommendations

• For patients with giant cell arteritis: Initiate high-dose glucocorticoids immediately to reduce stroke risk 5

• For patients with primary CNS angiitis: Use glucocorticoids for induction, followed by steroid-sparing agents for maintenance therapy 5

• For recreational or non-medical anabolic steroid use: Strongly advise against use due to documented risk of stroke even in young, healthy individuals 1, 2, 3

• For patients requiring therapeutic corticosteroids:

  • Monitor for cardiovascular risk factors
  • Use the lowest effective dose for the shortest duration possible
  • Consider steroid-sparing agents when appropriate 5, 6

• For men with hypogonadism: Testosterone replacement therapy can be used without increased stroke risk when properly indicated 5

Important Caveats and Pitfalls

• Do not use infliximab in patients with stroke and giant cell arteritis as it is associated with recurrent symptoms and increased disease activity (Class 3: Harm, Level B-R) 5

• Long-term steroid monotherapy in primary CNS angiitis is associated with higher relapse rates and poorer outcomes compared to adding steroid-sparing agents 5

• When tapering steroids in patients with giant cell arteritis or Takayasu arteritis, do so slowly to a target of ≤5 mg/day after 1 year to avoid exacerbation 5

• Be aware that corticosteroids can mask signs of infection and increase infection risk, which may indirectly impact stroke outcomes 6, 7