Is it appropriate to administer corticosteroids (steroids)?

Can You Give Steroids? It Depends on the Clinical Context

The decision to administer corticosteroids depends entirely on the specific clinical indication—steroids are strongly recommended for severe/critical COVID-19 and moderate-to-severe asthma exacerbations, but are contraindicated for empiric treatment of hoarseness/dysphonia without laryngoscopy and should not be routinely used for most cases of conjunctivitis or acute laryngitis.

When Steroids ARE Recommended

Severe or Critical COVID-19

• Systemic corticosteroids are strongly recommended for patients with severe or critical COVID-19, as they reduce 28-day mortality by 3.4% and probably reduce the need for mechanical ventilation 1
• The typical regimen involves 7-10 days of treatment, with dexamethasone being the preferred agent 1
• The benefits on mortality are deemed critically important, with minimal anticipated variability in patient preference when severely ill 1

Moderate-to-Severe Asthma Exacerbations

• Systemic corticosteroids should be administered to all patients with moderate-to-severe asthma exacerbations and those who fail to respond to initial β2-agonist therapy 1
• Oral prednisone is recommended as it has equivalent effects to intravenous methylprednisolone but is less invasive 1
• Early administration may reduce the likelihood of hospitalization in moderate-to-severe cases 1

Inflammatory Bowel Disease (Moderate-to-Severe)

• For moderate-to-severe Crohn's disease, oral prednisolone 40 mg daily is appropriate, with gradual tapering over 8 weeks 1, 2
• Intravenous steroids (hydrocortisone 400 mg/day or methylprednisolone 60 mg/day) are appropriate for severe disease 1, 2
• Budesonide 9 mg daily is suitable for isolated ileo-cecal disease with moderate activity 1, 2

Chronic Rhinosinusitis

• Topical intranasal steroids are effective for reducing symptoms of chronic rhinosinusitis and should be used for at least 8-12 weeks 1
• Long-term use has not been shown to affect systemic cortisol levels or increase ocular risks 1

When Steroids Are NOT Recommended

Hoarseness/Dysphonia Without Laryngoscopy

• Clinicians should NOT routinely prescribe corticosteroids for dysphonia prior to visualization of the larynx 1
• There are no studies supporting empiric steroid use for dysphonia except in special circumstances 1
• The potential for significant side effects (insomnia, gastrointestinal disturbances, mood changes, metabolic syndrome, cardiovascular risks) outweighs any unproven benefit 1

Acute Laryngitis

• Despite common prescription patterns, there is an overwhelming lack of supporting data for steroid efficacy in acute laryngitis 1
• The temptation to prescribe should be avoided due to potential serious side effects 1

ARDS/ALI (Routine Early Use)

• Do not routinely administer corticosteroids to patients at risk for or meeting criteria for ALI/ARDS 1
• Well-designed trials fail to demonstrate significant benefit for prevention or early treatment of ARDS 1
• Consider methylprednisolone only in persistent/refractory ARDS after actively excluding infection 1

Critical Safety Considerations

Contraindications and Cautions

• Use with extreme caution in patients with active or latent peptic ulcers, diverticulitis, fresh intestinal anastomoses, and nonspecific ulcerative colitis due to increased perforation risk 3
• Exercise caution in patients with diabetes (risk of hyperglycemia), immunocompromise, congestive heart failure, hypertension, or renal insufficiency 1, 3
• Avoid in patients with tuberculosis unless absolutely necessary for life-saving therapy 1

Dosing Principles

• Always use the lowest possible dose to control the condition, with gradual reduction when possible 3
• Short courses (<21 days) minimize risk, though side effects can occur even with brief use 1, 3
• Drug-induced adrenocortical insufficiency may persist up to 12 months after discontinuation following prolonged high-dose therapy 3

Monitoring Requirements

• For therapy >6 weeks, monitor intraocular pressure due to risk of elevated pressure, glaucoma, and cataracts 3
• In pediatric patients, carefully monitor growth velocity, blood pressure, weight, height, and bone health 3
• Consider osteoporosis prevention (calcium, vitamin D, bisphosphonates) for any patient anticipated to receive ≥5 mg prednisone equivalent for ≥3 months 3

Common Pitfalls to Avoid

• Never discontinue corticosteroids abruptly—gradual tapering is essential to prevent withdrawal syndrome and adrenal crisis 3
• Do not prescribe empirically without establishing a clear diagnosis, particularly for conditions like hoarseness where laryngoscopy is required first 1
• Warn patients about increased infection susceptibility, especially to chickenpox and measles, and advise seeking immediate medical attention if exposed 3
• Be aware that signs of peritoneal irritation following GI perforation may be minimal or absent in patients on steroids 3