What are the key differences and precautions when teaching about corticosteroids (e.g. prednisone) and anabolic steroids?

Teaching on Different Types of Steroids and Key Monitoring Points

Critical Distinction: Corticosteroids vs. Anabolic Steroids

These are fundamentally different drug classes with opposite purposes, mechanisms, and side effect profiles that must never be confused in clinical practice.

Corticosteroids (Anti-inflammatory/Immunosuppressive)

Purpose and Mechanism:

• Used to suppress inflammation and immune responses through multiple pathways including T cell apoptosis, suppression of inflammatory mediators, and stabilization of cell membranes 1
• Common examples include prednisone, prednisolone, dexamethasone, hydrocortisone, and inhaled formulations like beclomethasone 1
• Potency varies significantly: hydrocortisone is least potent, prednisone/methylprednisolone are 4-5 times more potent, and dexamethasone is approximately 25 times more potent than hydrocortisone 2

Key Clinical Applications:

• Acute exacerbations of inflammatory conditions (asthma, COPD, inflammatory bowel disease) 1
• Immune thrombocytopenia and other autoimmune conditions 1
• Chronic rhinosinusitis with nasal polyps 1
• Nephrotic syndrome 1

Critical Adverse Effects to Monitor:

Metabolic and Endocrine:

• HPA axis suppression is the most serious concern - can persist for up to 12 months after discontinuation following prolonged therapy 3
• Patients require stress-dose steroids during physiological stress (illness, surgery) if they have been on ≥20 mg/day prednisone for ≥2 weeks 4, 5
• Hyperglycemia, weight gain with centripetal fat distribution, and development of cushingoid features 3
• Sodium retention with edema and potassium loss requiring caution in heart failure, hypertension, or renal insufficiency 3

Musculoskeletal:

• Osteoporosis develops through decreased bone formation and increased resorption - all patients need calcium/vitamin D supplementation and consideration of bisphosphonates, especially postmenopausal women 3
• Growth suppression in children requires careful monitoring 3

Infectious:

• Masks signs of infection and decreases resistance to new infections 6
• Live vaccines are contraindicated in immunosuppressive doses 6
• Patients are at higher risk for severe chickenpox and measles 6

Ophthalmologic:

• Posterior subcapsular cataracts and glaucoma with prolonged use 6

Gastrointestinal:

• Increased risk of peptic ulcer perforation with minimal symptoms 3

Dosing Principles:

For Acute Treatment:

• Prednisone 40-60 mg daily (or 0.5-2 mg/kg/day) is standard for most acute inflammatory conditions 1
• Dexamethasone 40 mg daily for 4 days is an alternative that shows faster platelet response in ITP 1
• Duration should be limited to ≤6 weeks maximum - longer courses show no additional benefit but significantly increase adverse effects 1

Tapering Strategy:

• After 4-6 weeks of daily therapy, transition to alternate-day dosing to minimize HPA suppression 1, 3
• Reduce gradually as disease relapses commonly occur with doses <15 mg prednisone 1
• The diurnal rhythm matters: give morning doses to minimize HPA axis suppression since maximal adrenal activity occurs between 2-8 AM 3

Stress Dosing:

• For patients on chronic steroids (≥20 mg/day for ≥2 weeks), continue usual dose during acute illness rather than empiric stress dosing 5
• For severe illness with hypotension, give hydrocortisone 50-100 mg IV every 6-8 hours 4

Administration Technique for Topical Formulations:

Intranasal Sprays:

• Use contralateral hand technique (right hand for left nostril) to aim spray away from septum - this reduces epistaxis risk by 4-fold 1
• Keep head upright, breathe in gently during spraying 1
• Perform saline irrigation BEFORE steroid spray to avoid washing out medication 1
• Educate that onset of action is delayed (12 hours) with maximal efficacy in days to weeks - not for acute symptom relief 1
• Use regularly, not as-needed 1

Anabolic Steroids (Muscle-Building)

Purpose and Mechanism:

• Testosterone derivatives designed to increase muscle mass and strength through enhanced protein synthesis 7, 8
• Used clinically for hypogonadism, HIV-related wasting, severe burns, and specific bone marrow failure syndromes 8
• Illicit use by athletes for performance enhancement is common but associated with serious toxicity 8

Key Differences from Corticosteroids:

• Anabolic steroids BUILD tissue (increase muscle mass, bone density) while corticosteroids BREAK DOWN tissue (catabolic effects, muscle wasting, osteoporosis) 1, 7
• Anabolic steroids are controlled substances (Schedule III) due to abuse potential 8
• Testosterone levels are actually REDUCED by long-term corticosteroid therapy, creating opposite effects 9

Adverse Effects to Monitor:

In Men:

• Dose-dependent increase in hemoglobin (polycythemia risk) 1
• Decreased HDL cholesterol 1
• Prostate cancer growth stimulation - most concerning long-term risk 1
• Testicular atrophy and infertility with supraphysiologic doses 8

In Women:

• Virilization (deepening voice, facial hair, clitoral enlargement) occurs even at doses that produce muscle hypertrophy 1
• Difficult to find anabolic dose without masculinizing effects 1

In Both Sexes:

• Hepatotoxicity, especially with oral formulations 8
• Behavioral changes including aggression 8
• Altered coagulation factors 8
• Cardiovascular disease risk 8

Clinical Use in COPD:

• Low testosterone is common in men with COPD 1
• Testosterone enanthate 100 mg weekly increases lean body mass and leg strength 1
• Effects are approximately additive when combined with strength training 1
• No anabolic supplement has sufficient evidence for routine inclusion in pulmonary rehabilitation programs 1

Common Pitfalls and Teaching Points

Pitfall #1: Confusing the Two Drug Classes

• Patients may hear "steroids" and not understand the fundamental difference between anti-inflammatory corticosteroids and muscle-building anabolic steroids 7, 8
• Explicitly state: "The steroid I'm prescribing (prednisone) is completely different from the steroids athletes abuse - it reduces inflammation but can actually cause muscle weakness and bone loss" 1, 3

Pitfall #2: Abrupt Discontinuation

• Stopping corticosteroids suddenly after prolonged use can precipitate life-threatening adrenal crisis 3, 6
• Always taper gradually and educate patients about stress dosing needs for up to 12 months after stopping 3

Pitfall #3: Inadequate Osteoporosis Prevention

• All patients on chronic corticosteroids need calcium, vitamin D, and consideration of bisphosphonates BEFORE bone loss occurs 3
• Lifestyle modifications (weight-bearing exercise 30-60 minutes daily, smoking cessation, alcohol limitation) should be emphasized 3

Pitfall #4: Missing Contraindications

• Anabolic steroids are absolutely contraindicated in pregnant women, patients with prostate or breast cancer, and those with significant liver dysfunction 8
• Corticosteroids should be avoided in systemic fungal infections unless treating amphotericin B reactions 6

Pitfall #5: Incorrect Topical Steroid Technique

• Ipsilateral spray technique (same hand as nostril) causes 4-fold higher epistaxis and 3-fold higher discontinuation rates 1
• Patients need demonstration, not just verbal instructions, especially children and elderly 1

Pitfall #6: Using Corticosteroids Long-Term Without Steroid-Sparing Agents

• Patients requiring ≥2 corticosteroid courses per year or unable to taper below 15 mg prednisone should be started on steroid-sparing immunosuppressants (azathioprine, methotrexate, mycophenolate) 1
• Systemic corticosteroids should be avoided for chronic management when possible - reserved for acute exacerbations and bridge therapy 1