When should steroids be prescribed?

When Should Steroids Be Prescribed

Steroids should be prescribed only for specific conditions with established benefits, at the lowest effective dose for the shortest duration possible, after visualizing affected structures (when applicable), and with careful monitoring for side effects. 1

Appropriate Indications for Steroid Use

Neurological Conditions

• Steroids are indicated for patients with brain tumors who have symptomatic edema, but should be avoided in asymptomatic patients even if edema is visible on imaging 1
• For Bell's palsy, short-term steroids have demonstrated benefit 2
• For multiple sclerosis acute exacerbations, high-dose steroids (200 mg prednisolone daily for a week followed by 80 mg every other day for 1 month) are effective 3

Ear, Nose, and Throat Conditions

• For sudden sensorineural hearing loss (SSNHL), immediate steroid treatment is recommended, ideally within the first 14 days of onset 1
• Systemic steroids (prednisone 1 mg/kg/day, maximum 60 mg/day) should be given for 7-14 days followed by a taper over a similar period 1
• Intratympanic steroids may be used as initial treatment or as salvage therapy after systemic steroids fail 1

Autoimmune and Inflammatory Conditions

• For immune checkpoint inhibitor-related colitis, prednisone 1-2 mg/kg/day is recommended until symptoms improve to grade 1, followed by a 4-6 week taper 1
• For Duchenne muscular dystrophy, steroids should be initiated during the plateau phase of motor skills (typically age 4-8 years) rather than during skill acquisition or significant decline 1
• For autoimmune disorders affecting the larynx (lupus, sarcoidosis, granulomatosis with polyangiitis), steroids may be beneficial 1

Respiratory Conditions

• For asthma exacerbations, oral steroids (prednisolone 30-60 mg) are indicated 1
• For croup in pediatric patients with associated hoarseness, systemic steroids have shown benefit 1

Ophthalmologic Conditions

• For dry eye disease that is moderate to severe, short-term topical steroids are recommended, with weak potency steroids being acceptable for initial treatment 1
• For more severe dry eye disease, stronger potency steroids like betamethasone may be used 1

Conditions Where Steroids Should NOT Be Routinely Prescribed

• Empiric treatment of dysphonia/hoarseness prior to visualization of the larynx 1
• Acute laryngitis, which is typically viral and self-limiting 1
• Acute bronchitis, acute sinusitis, carpal tunnel syndrome, and allergic rhinitis 2
• Asymptomatic patients with brain tumors who have edema visible on imaging 1

Dosing Considerations

• The lowest effective dose should be used for the shortest time possible 1, 3
• Morning dosing (before 9 am) is preferred to minimize adrenal suppression 3
• For long-term therapy, alternate day therapy should be considered to reduce side effects 3
• Downward titration of the dose should be attempted whenever possible 1
• Abrupt withdrawal should be avoided; gradual tapering is necessary 3

Monitoring and Side Effect Management

Common Side Effects to Monitor

• Lipodystrophy, hypertension, cardiovascular disease, cerebrovascular disease 1
• Osteoporosis, impaired wound healing, myopathy 1
• Cataracts, peptic ulcers, infection, mood disorders 1
• Hyperglycemia, elevated blood pressure, sleep disturbance 2
• Venous thromboembolism, sepsis, fracture 2
• Edema, which may require dose reduction or diuretic use 4

Preventive Measures

• Patients with high risk of GI side effects (perioperative patients, history of ulcers/GI bleed, receiving NSAIDs or anticoagulation) should receive H2 blockers or proton pump inhibitors 1
• Dietary modification (low calorie, low sodium, high potassium) may help minimize some side effects 5
• Patients should carry a steroid treatment card and inform all healthcare providers about their steroid use 5

Special Considerations

• For professional voice users with known diagnosis, a shared decision-making approach should be used after discussing risks and limited evidence for benefit 1
• For children with Duchenne muscular dystrophy, complete the recommended national immunization schedule and establish varicella immunity before starting steroids 1
• For patients receiving immune checkpoint inhibitors who develop colitis, early introduction of biologics may be considered in addition to steroids for those with high-risk features 1

Pitfalls to Avoid

• Assuming short-term steroids are harmless; even brief courses can cause significant adverse effects 2
• Using steroids empirically without visualization of affected structures (e.g., larynx for dysphonia) 1
• Prescribing steroids for conditions where evidence shows no benefit or harm outweighs benefit 1, 2
• Stopping steroids abruptly, which can lead to adrenal crisis 3
• Failing to monitor for side effects, even with short-term use 2, 6