Contraindications to Steroid Pack Use

Systemic fungal infections and known hypersensitivity to corticosteroid components are absolute contraindications to steroid pack use. 1

Absolute Contraindications

Systemic fungal infections: Corticosteroids may exacerbate systemic fungal infections and should be avoided unless needed to control drug reactions 1
Known hypersensitivity: True allergic reactions to corticosteroids occur in approximately 0.3-0.5% of the general population, making documented allergy an absolute contraindication 2, 1
Active sepsis or abscess: Active infection risks overwhelming septicemia with immunosuppression 3

Latent or active tuberculosis: Reactivation of tuberculosis may occur; screen patients before initiating therapy and consider chemoprophylaxis during prolonged treatment 1
Hepatitis B carriers: Hepatitis B virus reactivation can occur; screen patients before immunosuppressive treatment and consult hepatology for monitoring and antiviral therapy 1
Varicella or measles exposure in non-immune patients: These infections can have serious or fatal courses; consider prophylaxis with varicella zoster immune globulin or immunoglobulin if exposure occurs 1
Strongyloides (threadworm) infestation: Corticosteroid-induced immunosuppression may lead to hyperinfection and dissemination with potentially fatal gram-negative septicemia 1
Latent or active amebiasis: Rule out amebiasis before initiating steroids in patients who have spent time in the tropics or have unexplained diarrhea 1
Cerebral malaria: Avoid corticosteroids in these patients 1
Active ocular herpes simplex: Risk of corneal perforation 1

Uncontrolled hypertension: Listed as a relative contraindication due to risk of blood pressure elevation 3
Uncontrolled diabetes: Hyperglycemia is a significant concern requiring blood glucose monitoring 3
Existing cardiac failure: Corticosteroids may exacerbate heart failure 3

Acute peptic ulcer disease: Risk of gastritis and ulcer complications; consider prophylactic H2 blockers or proton pump inhibitors in high-risk patients 3

Severe behavioral symptoms that worsen with corticosteroids: Psychiatric complications occur in nearly 6% of patients (severe reactions) and 28% (mild-moderate reactions), including psychosis, mania, depression, and delirium 3, 4, 5, 6
History of steroid-induced psychosis: Neither presence nor absence of previous reactions predicts future responses, but severe psychiatric history warrants caution 6

Glaucoma or cataracts: Corticosteroids may produce posterior subcapsular cataracts and glaucoma with possible optic nerve damage 1
Optic neuritis: Oral corticosteroids are not recommended and may increase risk of new episodes 1

History of malignancy: Best avoided due to theoretical risk of lymphoproliferative disorders, though post-marketing surveillance has not confirmed this risk 3
Kaposi's sarcoma: May occur or worsen with corticosteroid therapy 1

Interleukin-2 (aldesleukin) or interferon therapy: Steroid use is contraindicated with these immunotherapy agents 3
Immune checkpoint inhibitors: While steroids are used to manage immune-related adverse events, timing and dosing require careful consideration 3

Do not delay tuberculosis testing before initiating anti-TNF therapy for acute severe conditions, but screening should be performed when feasible 3
Avoid indiscriminate premedication with steroids for suspected allergic reactions without proper evaluation, as this may mask true hypersensitivity 2
Consider structural class alternatives: Patients with documented allergy to one corticosteroid group can often tolerate corticosteroids from different structural classes 2
Recognize increased infection risk: Chronic steroid use increases susceptibility to pyogenic bacteria, intracellular pathogens (Listeria), fungi, herpes viruses, and certain parasites; risk correlates with dose and duration 7