What are the recommendations for using systemic steroid injections?

Recommendations for Systemic Steroid Injections

Systemic steroid injections should generally be avoided for most conditions due to significant short-term and long-term adverse effects that largely outweigh the benefits, and should only be considered for short-term use in severe, rapidly progressive, or debilitating cases while other therapies are being initiated. 1

General Recommendations

• Systemic steroids (oral or parenteral) should generally be avoided in adults and children with atopic dermatitis because the potential short-term and long-term adverse effects largely outweigh the benefits 1
• Systemic steroids are not recommended in eosinophilic esophagitis (EoE) in either pediatric or adult patients in non-stricturing disease (high-grade evidence, strong recommendation) 1
• When absolutely necessary for acute flares, systemic steroids should be limited to the lowest effective dose for the shortest duration possible 2

Appropriate Limited Use Cases

• Systemic steroids may be considered for short-term use in individual cases while other systemic or phototherapy regimens are being initiated and/or optimized 1
• In atopic dermatitis, systemic steroids may be considered as a transitional therapy in severe, rapidly progressive, or debilitating cases while non-steroid immunomodulatory agents or phototherapy is being initiated 1
• In children with EoE with stricturing disease, systemic steroids have shown resolution of strictures in 95% of cases, though this is not the first-line treatment 1

Dosage and Administration

• The most commonly used formulations of systemic steroids are prednisone, prednisolone, and triamcinolone acetonide 1
• Prednisone and prednisolone are available as tablets or oral solutions for enteral administration, while triamcinolone acetonide is available as a suspension for intramuscular injection 1
• Dosing is generally based on body weight, with most providers using a dosage range of 0.5-1.0 mg/kg 1
• A taper is indicated to decrease the risk of adrenal suppression 1

Adverse Effects

• Short and long-term side effects include: hypertension, glucose intolerance, gastritis, weight gain, decreased bone density, adrenal suppression, and emotional lability 1
• Pediatric patients experience decreased linear growth while on the medication 1
• Immunosuppression increases the risk of infection with any pathogen, including viral, bacterial, fungal, protozoan, or helminthic pathogens 3
• Rebound flare and increased disease severity is a commonly observed phenomenon upon discontinuation of systemic steroids 1
• Systemic effects can occur even with locally administered corticosteroids (injections, inhaled, topical) 4, 5, 6

Monitoring Requirements

• Patients on long-term systemic steroids may require blood pressure monitoring, ophthalmologic examination, hypothalamic-pituitary-adrenal axis suppression testing, bone density evaluation (adults), and growth-velocity measurement (children) 1
• Patients with diabetes require close monitoring of blood glucose levels 3
• Coagulation indices should be monitored frequently in patients taking warfarin concurrently with corticosteroids 3

Special Considerations

Pediatric Patients

• Children and adolescents given systemic steroids can experience decreased linear growth 1
• Systemic steroids are not recommended for children with atopic dermatitis unless required to manage comorbid conditions (such as asthma exacerbations) 1

Patients with Tympanic Membrane Perforations

• When a perforation is present or suspected, clinicians should prescribe a non-ototoxic topical preparation to avoid potential hearing damage 7
• Consider systemic administration rather than topical or intratympanic routes if steroids are deemed necessary in patients with perforations 7

Degenerative Joint Disease

• Disease-modifying antirheumatic drugs (DMARDs) are preferred over long-term glucocorticoids for inflammatory joint conditions 2
• Biologic DMARDs are strongly recommended over long-term glucocorticoids for persistent joint inflammation 2

Drug Interactions

• Co-administration with potassium-depleting agents (e.g., amphotericin B, diuretics) requires close monitoring for hypokalemia 3
• Macrolide antibiotics can significantly decrease corticosteroid clearance 3
• Anticholinesterase agents and corticosteroids may produce severe weakness in patients with myasthenia gravis 3
• Corticosteroids may increase blood glucose concentrations, requiring dosage adjustments of antidiabetic agents 3

Risk Mitigation

• Patients should be warned not to discontinue corticosteroids abruptly or without medical supervision 3
• Patients should avoid exposure to chickenpox or measles and seek medical advice immediately if exposed 3
• Calcium and vitamin D supplementation, bisphosphonate therapy, and weight-bearing exercise are recommended to reduce the risk of adverse bone effects 3
• Patients should be transitioned to steroid-sparing agents as soon as feasible 2