What are the benefits and risks of using steroids, such as prednisone (corticosteroid), for medical conditions?

Corticosteroids in Medical Practice: Benefits and Risks

Corticosteroids like prednisone are highly effective anti-inflammatory and immunosuppressive agents with proven benefits in numerous conditions, but their use must be carefully balanced against significant risks including infection, osteoporosis, adrenal suppression, cardiovascular disease, and metabolic complications. 1

Primary Benefits

Anti-inflammatory and Immunosuppressive Effects

• Corticosteroids suppress genomic expression of proinflammatory proteins including COX-2, IL-1, IL-2, IL-6, TNF-alpha, and adhesion molecules 2
• They control inflammatory features in conditions like rheumatoid arthritis, inflammatory bowel disease, and immune-related adverse events from cancer immunotherapy 3, 4, 2
• In rheumatoid arthritis specifically, low-dose prednisone (5-10 mg daily) retards bony damage and represents an original disease-modifying antirheumatic drug 2

Specific Clinical Indications with Proven Benefit

• Inflammatory Bowel Disease: Oral prednisolone 40 mg daily effectively induces remission in moderate-to-severe Crohn's disease; IV steroids (hydrocortisone 400 mg/day or methylprednisolone 60 mg/day) for severe disease 4
• Immune checkpoint inhibitor toxicity: Hydrocortisone 50-100 mg IV every 6-8 hours for severe adrenal insufficiency (Grade 3-4), with maintenance dosing of 15-20 mg daily in divided doses 3
• Advanced cancer: Stimulates appetite, improves mood and activity, provides analgesic-sparing effects, and relieves nerve compression pain 5
• Infectious complications: Reduces mortality in severe alcoholic hepatitis with encephalopathy and decreases complications in H. influenzae or M. tuberculosis meningitis 6

Liver Safety Profile

• Corticosteroids are generally safe for the liver at standard therapeutic doses and are actually used to treat certain types of hepatitis and alcoholic hepatitis 7

Major Risks and Adverse Effects

Immunosuppression and Infection Risk

• Corticosteroids suppress immune function and increase risk of infection with any pathogen (viral, bacterial, fungal, protozoan, helminthic) 1
• They reduce resistance to new infections, exacerbate existing infections, increase disseminated infection risk, and mask signs of infection 1
• Risk of infectious complications increases proportionally with dosage 1
• Tuberculosis reactivation can occur in patients with latent TB or tuberculin reactivity 1
• Hepatitis B reactivation can occur in carriers; screening is required before initiating immunosuppressive treatment 1
• Varicella and measles can have serious or fatal courses in non-immune patients taking corticosteroids 1

Perioperative Complications

• Patients on corticosteroids undergoing IBD surgery have increased risk of postoperative infectious complications and anastomotic leaks 3
• Risk is greater with doses ≥40 mg prednisolone, though some evidence shows increased risk even at ≥15-20 mg 3
• Corticosteroids should be stopped or minimized before elective surgery wherever possible 3
• Patients remaining on steroids perioperatively should receive IV hydrocortisone in equivalent dosage until oral intake resumes (prednisolone 5 mg = hydrocortisone 20 mg) 3

Cardiovascular and Metabolic Effects

• Elevation of blood pressure, salt and water retention, increased potassium excretion 1
• Association with left ventricular free wall rupture after recent myocardial infarction 1
• Increased risk of atrial fibrillation, particularly with oral corticosteroids at treatment initiation, short-term use, and high doses (≥7.5 mg prednisone equivalents) 3
• Diabetogenesis and worsening glucose control 3, 1

Endocrine Complications

• Reversible hypothalamic-pituitary-adrenal (HPA) axis suppression with potential for adrenocortical insufficiency after withdrawal 1
• This relative insufficiency may persist up to 12 months after discontinuation 1
• Symptoms include fatigue, weakness, anorexia, nausea, vomiting, abdominal pain, hypotension, and electrolyte abnormalities 8
• Diagnosis requires cosyntropin stimulation test with peak cortisol <500 nmol/L diagnostic of adrenal insufficiency 8

Musculoskeletal Effects

• Osteoporosis and increased fracture risk 3, 8
• Avascular necrosis of femur, humerus, and long bones 3
• Steroid myopathy 3
• Impaired wound healing 3

Other Significant Adverse Effects

• Cataracts and ophthalmologic disorders 3
• Peptic ulcers 3
• Mood disorders 3
• Skin disorders including cutaneous atrophy and alopecia 3
• Pancreatitis 3
• Lipodystrophy and weight gain 3, 8

Critical Management Principles

Avoid Empiric Use Without Clear Indication

• Corticosteroids should NOT be routinely prescribed for hoarseness/dysphonia due to significant risk profile and limited evidence of benefit 3
• Due to potential for serious side effects, steroids should not be used empirically; diagnosis must be known and treatment targeted 3
• For hoarseness, if used at all, should be reserved for specific situations like allergic laryngitis in professional voice users after shared decision-making 3

Steroid Dependency and Excess

• Steroid dependency occurs in approximately 15% of IBD patients and represents failure of appropriate disease management 4
• Steroid excess (≥2 courses over 1 year) is associated with increased mortality, particularly in Crohn's disease 8, 4
• Prolonged use (>3 months) causes increased infection risk, osteoporosis, HPA axis suppression, diabetes, weight gain, and cardiovascular disease 8, 4

Steroid-Sparing Strategies

• When patients require steroids more than once per year or cannot be weaned, initiate immunomodulation with azathioprine (1.5-2.5 mg/kg/day), mercaptopurine (0.75-1.5 mg/kg/day), or methotrexate (25 mg IM weekly) 4
• Biologics like infliximab should be reserved for steroid-refractory disease 4

Tapering and Withdrawal

• Adrenocortical insufficiency may result from too rapid withdrawal; minimize by gradual dose reduction 1
• Prednisolone should be reduced gradually over 8 weeks according to severity and patient response 4
• More rapid reduction is associated with early relapse 4
• Abrupt discontinuation should never occur without medical supervision 8

Stress Dosing Requirements

• In any stressful situation occurring within 12 months of discontinuation, hormone therapy should be reinstituted 1
• Patients already on steroids may require increased dosage during stress 1
• All patients need education on stress dosing for sick days, use of emergency injectables, when to seek medical attention for impending adrenal crisis, and medical alert identification 3
• For unexplained hypotension during surgery unresponsive to fluids, consider adrenal insufficiency and administer 100 mg IV hydrocortisone 8

Monitoring and Prevention

• Bone mineral density assessment by densitometry for patients on long-term steroids, particularly those with high FRAX scores 8
• Calcium and vitamin D supplementation recommended to reduce bone disease risk 8
• Screen for hepatitis B before initiating immunosuppressive treatment 1
• Monitor blood pressure, weight, glucose, and electrolytes regularly 1
• In pediatric patients, monitor growth velocity as it may be more sensitive indicator of systemic exposure than HPA axis testing 1

Special Populations

• Elderly patients: Increased risk of diabetes, fluid retention, and hypertension; start at low end of dosing range 1
• Pediatric patients: May experience decreased growth velocity even at low doses without HPA axis suppression; titrate to lowest effective dose 1
• Pregnancy/lactation: Corticosteroids enter breast milk; decision to discontinue nursing or drug must consider importance to mother 1
• Vaccination: Measles and varicella immunizations should be deferred 11 months after high-dose IVIG; consider prophylaxis if exposure occurs 3

Common Pitfalls to Avoid

• Using corticosteroids as maintenance therapy in IBD (they have no role in preventing relapse) 4
• Failing to implement steroid-sparing strategies when patients require repeated courses 4
• Abrupt discontinuation without tapering 8, 1
• Not educating patients about adrenal insufficiency symptoms and stress dosing 3, 8
• Prescribing antibiotics concurrently for viral laryngitis causing hoarseness 3
• Using high perioperative "push-dose" steroids routinely (insufficient evidence supports this practice) 8
• Failing to screen for latent tuberculosis or hepatitis B before prolonged therapy 1