What is the role of steroids in medical treatment?

Role of Steroids in Medical Treatment

Steroids serve critical therapeutic roles across multiple medical conditions, with their use guided by specific disease contexts, dosing strategies, and careful monitoring for significant adverse effects.

Severe Alcoholic Hepatitis

For patients with severe alcoholic hepatitis (Maddrey Discriminant Function score ≥32), prednisolone 40 mg/day for 28 days represents first-line therapy and can reduce short-term mortality by approximately 30%. 1

• Meta-analysis of pooled primary data demonstrated significant improvement in short-term survival: 84.6% versus 65% in treated versus control patients, translating to a number needed to treat of 5 1
• Prednisolone is preferred over prednisone based on best available evidence 1
• Treatment should typically be followed by either discontinuation or a 2-4 week taper depending on clinical response 1
• Critical exclusion criteria: Steroids have not been evaluated and should be avoided in patients with concomitant pancreatitis, gastrointestinal bleeding, renal failure, or active infection 1
• Patients with MDF >54 may experience higher mortality risk from steroid treatment than from no treatment, though this threshold requires confirmation 1
• For patients with contraindications to steroids, pentoxifylline 400 mg orally three times daily for 4 weeks is an alternative option 1

Metastatic Brain Tumors

Dexamethasone represents a mainstay of treatment for symptomatic brain metastases, with 4-8 mg/day being as effective as higher doses in patients without symptomatic intracranial hypertension. 1

• Randomized trials demonstrated no advantage to 16 mg/day compared to 4-8 mg/day dosing in patients with Karnofsky Performance Status ≤80 1
• Both dosing groups showed improvement in functional status without significant differences in outcomes 1
• Use the lowest effective dose to minimize toxicity while maintaining symptom control 1
• Complications including adrenal insufficiency with tapering require ongoing monitoring 1

Inflammatory Bowel Disease with Spondyloarthritis

Short-term systemic glucocorticoids can be used for rapid induction of remission in moderate-to-severe IBD with musculoskeletal manifestations, but only as a bridge to steroid-free maintenance therapies. 1

• Local steroid injections are effective for peripheral oligoarthritis (≤4 joints), enthesitis, and dactylitis 1
• Systemic steroids provide fast symptomatic relief but long-term use must always be avoided 1
• For peripheral SpA with moderate-to-severe active IBD, TNF inhibitors (infliximab, adalimumab, or golimumab) are recommended as first-line treatment after failure of sulfasalazine or methotrexate 1

Immune Checkpoint Inhibitor Therapy

Short courses of steroids to treat immune-related adverse events do not negatively affect ICI efficacy, but baseline steroid use ≥10 mg prednisone daily for palliative indications is associated with worse outcomes. 1

• Transient, on-treatment steroid use for managing immune-related adverse events does not compromise survival outcomes 1
• Baseline prednisone >10 mg daily for palliative care was associated with significantly worse OS (2.2 versus 11.2 months; HR 2.38) 1
• However, steroids used for cancer-unrelated indications showed no significant survival difference (10.7 versus 11.2 months; HR 0.93) 1
• Clinical decision-making should be individualized: neither exclude patients receiving steroids from ICI therapy nor routinely discontinue steroids at immunotherapy initiation 1

Kawasaki Disease

High-dose IVIG (2 g/kg) remains the standard treatment for Kawasaki disease, with steroids reserved for IVIG-refractory cases. 1

• Initial therapy with corticosteroids is not recommended based on historical concerns, though more recent data suggest possible benefit 1
• For IVIG-refractory disease: Intravenous pulse methylprednisolone 30 mg/kg for 2-3 hours daily for 1-3 days is the most commonly used regimen 1
• Small randomized trials showed that adding methylprednisolone to conventional IVIG therapy shortened fever duration and hospital stays without clear differences in coronary outcomes 1
• Multicenter controlled trials are needed to definitively establish the role of steroids in initial therapy 1

Critical Safety Considerations

Infection Risk

Steroids suppress immune function and increase infection risk across all pathogens, with rates increasing proportionally to dosage. 2

• Monitor closely for development of infections and consider dose reduction or withdrawal as needed 2
• Reactivation of latent tuberculosis may occur; patients with latent TB or tuberculin reactivity should receive chemoprophylaxis during prolonged therapy 2
• Screen for hepatitis B before initiating immunosuppressive steroid treatment, as reactivation can occur 2
• Varicella and measles can have serious or fatal courses in non-immune patients taking steroids 2

Adrenal Insufficiency

Gradual dose reduction is essential to minimize drug-induced secondary adrenocortical insufficiency, which may persist for months after discontinuation. 2

• During any stressful situation occurring after steroid withdrawal, hormone therapy should be reinstituted 2
• Salt and/or mineralocorticoid supplementation may be needed concurrently 2

Dose Optimization

Always use the lowest effective steroid dose to control the underlying condition, as edema and other adverse effects are dose-dependent. 3

• Consider alternate-day dosing or switching steroid formulations to reduce side effects while maintaining therapeutic effect 3
• Monitor blood pressure, as both steroids and any concurrent diuretics can affect blood pressure 3

Long-Term Monitoring Requirements

Prolonged steroid use requires systematic monitoring for multiple complications beyond the primary therapeutic indication. 3

• Monitor for osteoporosis, diabetes, hypertension, and increased infection risk 3
• Consider PJP prophylaxis for patients requiring steroid treatment >4 weeks 3
• Growth and development must be carefully observed in infants and children on prolonged therapy 2

Hepatic Safety

Corticosteroids are generally safe for the liver at standard therapeutic doses and are actually used to treat certain types of hepatitis. 4

• This favorable liver safety profile is supported by their therapeutic use in alcoholic hepatitis and other hepatic conditions 1, 4

Drug Interactions

Multiple clinically important drug interactions require dose adjustments and monitoring. 2

• Cyclosporine: mutual inhibition of metabolism increases risk of adverse events; convulsions reported with concurrent use 2
• Phenobarbital, phenytoin, rifampin: increase methylprednisolone clearance, requiring dose increases 2
• Troleandomycin, ketoconazole: inhibit metabolism, requiring dose reduction to avoid toxicity 2
• Chronic high-dose aspirin: methylprednisolone may increase clearance, risking salicylate toxicity upon withdrawal 2
• Anticoagulants: variable effects require monitoring of coagulation indices 2

Common Pitfalls

• Never abruptly discontinue steroids due to risk of adrenal insufficiency 3
• Avoid using steroids in patients with active systemic fungal infections unless needed to control drug reactions 2
• Do not use steroids in cerebral malaria 2
• Exercise caution in patients with ocular herpes simplex due to risk of corneal perforation 2
• Be aware of increased scleroderma renal crisis risk in patients with systemic sclerosis 2
• Tumor lysis syndrome has been reported in patients with malignancies following systemic corticosteroid use; monitor high-risk patients closely 2