What are the possible long-term complications of prednisone (corticosteroid) therapy?

Long-Term Complications of Prednisone Therapy

Long-term prednisone therapy can cause numerous serious complications affecting multiple organ systems, with risk increasing with higher doses and longer duration of treatment. 1, 2

Common Systemic Complications

Musculoskeletal Effects

• Osteoporosis and increased fracture risk are among the most serious complications, particularly in postmenopausal women 3, 1
• Vertebral compression fractures can occur in up to 27% of patients requiring treatment withdrawal 3
• Aseptic necrosis of femoral and humeral heads can develop even at moderate doses 3, 1
• Myopathy affecting diaphragmatic and intercostal muscles may complicate assessment of therapeutic efficacy 3

Metabolic and Endocrine Effects

• Hyperglycemia and worsening of diabetes are common, requiring regular blood glucose monitoring 1, 2
• Hypothalamic-pituitary-adrenal (HPA) axis suppression can occur, leading to adrenal insufficiency after withdrawal 2
• Hypokalemia, metabolic alkalosis, and salt/water retention may develop, causing or worsening hypertension 2
• Dyslipidemia increases risk of cardiovascular disease with long-term use 1
• Redistribution of body fat with truncal obesity, moon facies, and buffalo hump occurs in 80% of patients after two years of therapy 3

Ophthalmologic Effects

• Posterior subcapsular cataracts develop with prolonged use 3, 1
• Increased intraocular pressure and glaucoma can occur, requiring regular monitoring 3, 1

Neuropsychiatric Effects

• Mood disturbances ranging from euphoria to severe depression and psychosis 3, 1
• Sleep disturbances affect >30% of patients taking corticosteroids 1
• Emotional instability and personality changes may be exacerbated 2

Immunologic Effects

• Increased risk of both opportunistic and non-opportunistic infections 1, 2
• Reactivation of latent infections like tuberculosis and hepatitis B 2
• Masking of infection signs, potentially delaying diagnosis 2

Dermatologic Effects

• Skin thinning, purpura, and striae develop with prolonged use 1, 4
• Impaired wound healing can occur 2

Gastrointestinal Effects

• Increased risk of peptic ulcer disease, especially with concomitant NSAID use 2, 5
• Pancreatitis has been reported with long-term use 5

Risk Factors for Complications

• Doses exceeding 10 mg daily for more than 18 months significantly increase risk of severe complications 3, 1
• Pre-existing conditions like diabetes, hypertension, and osteoporosis increase risk 3, 1
• Elderly patients have higher risk of complications at equivalent doses 1
• Concomitant use of medications that interact with prednisone (e.g., warfarin, fluoroquinolones) 2

Monitoring Recommendations

Bone Health

• Baseline and annual bone mineral density testing for patients on long-term therapy 3, 1
• Regular assessment for vertebral compression fractures 3

Metabolic Monitoring

• Regular blood glucose monitoring, especially in diabetic patients 1, 2
• Blood pressure monitoring at each visit 1, 2
• Periodic electrolyte assessment, particularly potassium 2
• Lipid profile monitoring to assess cardiovascular risk 1

Ophthalmologic Monitoring

• Regular eye examinations for cataracts and glaucoma 3, 1
• More frequent monitoring for patients with pre-existing eye conditions 3

Infection Surveillance

• Vigilance for signs of infection, which may be masked by corticosteroid therapy 2
• Consider tuberculosis screening in high-risk patients 2
• Hepatitis B screening before initiating long-term therapy 2

Prevention Strategies

Bone Protection

• Calcium (1000 mg/day) and vitamin D (400-800 IU/day) supplementation 1, 6
• Consider bisphosphonates for high-risk patients or those with established osteoporosis 6
• Regular weight-bearing exercise to maintain bone mass 1, 6

Minimizing Steroid Exposure

• Use the lowest effective dose for the shortest duration possible 1, 4
• Consider alternate-day therapy when appropriate to reduce adrenal suppression 1
• Evaluate steroid-sparing agents when long-term therapy is anticipated 1

Gastrointestinal Protection

• Consider proton pump inhibitors for patients at high risk of peptic ulcer disease 5

Infection Prevention

• Update all vaccinations before starting immunosuppressive therapy 1
• Avoid live vaccines in patients already taking immunosuppressants 1
• Consider Pneumocystis jirovecii pneumonia prophylaxis for patients on high-dose therapy 1

Special Considerations

• Children on long-term therapy are at risk for growth suppression 3, 1
• Pregnant patients should only receive therapy when benefits outweigh risks 4
• Surgical patients on long-term steroids may require stress-dose steroids 4

By understanding these potential complications and implementing appropriate monitoring and preventive strategies, the risks associated with long-term prednisone therapy can be minimized while maintaining therapeutic benefits.