Steroid-Induced Coordination Issues: Management
Coordination problems from corticosteroids like prednisone represent steroid-induced myopathy, which requires immediate dose reduction of approximately 25-33% and consideration of steroid-sparing agents to maintain treatment efficacy while minimizing neuromuscular toxicity. 1, 2
Understanding Steroid-Induced Myopathy
Steroid-induced myopathy is a well-recognized complication of corticosteroid therapy that manifests as generalized weakness and coordination difficulties. An acute myopathy has been observed with high doses of corticosteroids, is generalized, may involve ocular and respiratory muscles, and may result in quadriparesis. 3 This condition is directly related to cumulative steroid dose and duration of therapy. 2
The FDA drug label for prednisone specifically warns that this acute myopathy most often occurs in patients with disorders of neuromuscular transmission (e.g., myasthenia gravis) or in patients receiving concomitant therapy with neuromuscular blocking drugs, and elevation of creatinine kinase may occur. 3
Immediate Management Algorithm
Step 1: Dose Reduction
If glucocorticoid side-effects are unmanageable and/or not tolerable, then a decrease in dose is necessary, whether motor function is stable or in decline. 1 A reduction of approximately 25-33% is recommended, with reassessment by phone or clinical visit in 1 month to determine whether side-effects have been controlled. 1
Step 2: Implement Steroid-Sparing Agents
The American College of Physicians recommends implementing a steroid-sparing agent concurrently with dose reduction to maintain treatment of the underlying condition, as weakness is significantly related to cumulative steroid dose. 2
Specific steroid-sparing options include:
Methotrexate: Start at 15 mg weekly with 1 mg/day folic acid supplementation, targeting 25 mg weekly within 3-6 months 2
Azathioprine: Target dose of 2 mg/kg of ideal body weight in divided doses, starting at 25-50 mg/week with increments of 25-50 mg/week 2
Mycophenolate mofetil: Start at 500 mg twice daily, increasing by 500 mg weekly until reaching 1000 mg twice daily 2
Step 3: Consider Alternative Steroid Regimens
If daily dosing generates unmanageable coordination issues not ameliorated by dose reduction, change to an alternative regimen. 1
Alternative regimens (in order of preference):
Alternate day dosing: Prednisone 0.75-1.25 mg/kg every other day (less effective but consider when daily schedule has intolerable side-effects) 1
High-dose weekend: 5 mg/kg given each Friday and Saturday (less data on effectiveness but consider if weight gain and behavioral issues are problematic) 1
Intermittent dosing: 0.75 mg/kg for 10 days alternating with 10-20 days off medication (least effective but possibly best tolerated regimen before abandoning steroid treatment) 1
Severe or Refractory Cases
For severe weakness (Grade 3-4) with inadequate response to dose reduction, IVIG therapy (1-2 g/kg) may be considered. 2 However, this should only be pursued after attempting dose reduction and steroid-sparing agents. 1
Recovery Timeline
Clinical improvement or recovery after stopping corticosteroids may require weeks to years. 3 This prolonged recovery period underscores the importance of early recognition and intervention when coordination issues develop.
Critical Monitoring Parameters
Patients on chronic corticosteroid therapy require attentive management of side-effects, and this should be managed in clinics with appropriate expertise. 1 Specific monitoring should include:
- Assessment of muscle strength and coordination at each visit 1
- Creatinine kinase levels if myopathy is suspected 3
- Evaluation for concomitant medications that may worsen neuromuscular effects (anticholinesterase agents should be withdrawn at least 24 hours before initiating corticosteroid therapy if possible) 3
When to Discontinue Steroids
Glucocorticoid therapy should not be abandoned even if side-effects are not manageable and/or tolerable until at least one dose reduction and change to an alternative regimen has been pursued. 1 However, should adjustments to the glucocorticoid dosing and/or schedule regimens prove ineffective in making coordination issues sufficiently manageable and tolerable, then it is necessary to discontinue glucocorticoid therapy, irrespective of the state of the underlying condition. 1
Common Pitfalls to Avoid
Do not continue high-dose steroids hoping coordination will improve spontaneously - myopathy is dose-dependent and will worsen with continued exposure. 2, 3
Do not abruptly discontinue steroids - patients should be warned not to discontinue the use of corticosteroids abruptly or without medical supervision, as prolonged use may cause adrenal insufficiency. 3
Do not use concomitant anticholinesterase agents - concomitant use of anticholinesterase agents and corticosteroids may produce severe weakness in patients with myasthenia gravis, and if concomitant therapy must occur, it should take place under close supervision with anticipated need for respiratory support. 3