What are the potential side effects of high dose steroid therapy, such as prednisone (corticosteroid), and how can they be minimized?

Side Effects of High Dose Steroids and Minimization Strategies

High dose steroid therapy, particularly with prednisone, can cause numerous significant side effects affecting multiple body systems, and minimization strategies should include using the lowest effective dose for the shortest duration possible, considering alternate-day therapy when appropriate, and implementing specific preventive measures for known complications.

Common Side Effects of High Dose Steroids

Metabolic and Endocrine Effects

• Hyperglycemia and worsening of diabetes 1
• Weight gain and increased appetite 1, 2
• Fluid retention and sodium retention 2
• Hypertension 1
• Lipodystrophy (abnormal fat distribution) 1
• Hypothalamic-pituitary-adrenal (HPA) axis suppression 2

Musculoskeletal Effects

• Osteoporosis and increased fracture risk 1
• Osteonecrosis (avascular necrosis), particularly in patients with preexisting bone or joint problems 1
• Muscle weakness and myopathy 1
• Growth suppression in children 2

Dermatologic Effects

• Acne 1
• Easy bruising 1
• Facial swelling and moon face 1, 3
• Increased growth of body hair 1
• Striae (stretch marks) 1

Immunologic Effects

• Increased susceptibility to infections 1, 2
• Masking of infection signs 2
• Reactivation of latent infections (especially tuberculosis) 2
• Risk of severe complications from varicella (chickenpox) and measles 2

Ophthalmologic Effects

• Cataracts 1
• Glaucoma 1
• Blurred vision 1

Neuropsychiatric Effects

• Insomnia 1
• Mood swings 1
• Nervousness/restlessness 1
• Psychosis (with higher doses) 4

Gastrointestinal Effects

• Gastric irritation 1
• Peptic ulcers 1
• Pancreatitis (rare) 4

Minimizing Side Effects

Dosing Strategies

• Use the minimum effective dose for the shortest duration possible 5
• Consider alternate-day therapy once disease is controlled to reduce HPA axis suppression 2
• Morning dosing (single dose) to mimic natural cortisol rhythm 5
• Avoid dividing doses when possible 1
• Taper steroids gradually rather than stopping abruptly to prevent adrenal insufficiency 2

Specific Preventive Measures

• For osteoporosis prevention:

  • Calcium and vitamin D supplementation 1, 6
  • Consider bone mineral density monitoring with DEXA scans 1, 6
  • For high-risk patients (≥40 years with high-dose therapy ≥30mg daily for ≥30 days or cumulative dose ≥5g over 1 year), consider bisphosphonates 1

• For infection prevention:

  • Screen for tuberculosis before initiating high-dose therapy 2
  • Consider prophylaxis for patients exposed to varicella or measles 2
  • Monitor for signs of infection that may be masked by steroid therapy 2

• For metabolic complications:

  • Low-calorie, low-sodium, high-potassium diet 5
  • Regular monitoring of blood glucose, especially in diabetic patients 1
  • Blood pressure monitoring 1

• For gastrointestinal protection:

  • Consider proton pump inhibitors or H2 blockers in high-risk patients 4

Special Populations

• Pregnant patients:

  • Use only if benefits outweigh risks as steroids can cross placenta 2
  • Monitor closely as steroids are associated with increased risk of premature delivery 1

• Children:

  • Monitor growth velocity as it may be a sensitive indicator of systemic steroid effect 2
  • Titrate to lowest effective dose to minimize growth effects 2

• Elderly patients:

  • Start at lower doses due to increased risk of adverse effects 2
  • Monitor closely for diabetes, hypertension, and fluid retention 2

• Surgical patients:

  • If possible, reduce steroid dose before elective surgery 1
  • For patients on long-term steroids requiring surgery, stress-dose steroids may be needed 1

Monitoring Recommendations

• Regular clinical assessment for side effects 1
• Blood pressure monitoring 2
• Blood glucose monitoring 2
• Bone mineral density assessment for long-term use 1
• Ophthalmologic evaluation for cataracts and glaucoma with prolonged use 1
• Weight monitoring 2

By implementing these strategies, the risk of adverse effects from high-dose steroid therapy can be significantly reduced while maintaining therapeutic benefits.