What are the guidelines for one-time corticosteroid (corticosteroid) use in adolescents?

One-Time Corticosteroid Use in Adolescence

Short courses of systemic corticosteroids (≤14 days) in adolescents are generally safe with minimal risk of serious adverse events, though clinicians should monitor for hyperglycemia, sleep disturbances, and gastrointestinal bleeding. 1

Safety Profile of Short-Course Corticosteroids

Moderate-certainty evidence demonstrates that short-term corticosteroid use (≤14 days) is not associated with serious adverse events, treatment discontinuation, or behavioral changes in children and adolescents. 1 A meta-analysis of 6,470 children found no increased risk of serious adverse events (1 fewer event per 1000 patients; 95% CI, 9 fewer to 7 more) or behavioral changes (8 more events per 1000 patients; 95% CI, 5 fewer to 21 more). 1

Expected Adverse Events

The following adverse events occur with increased frequency but are rarely serious:

• Hyperglycemia: 38 additional cases per 1000 patients (95% CI, 11 to 64 more cases) with moderate certainty evidence 1
• Sleep disturbances: 15 additional cases per 1000 patients (95% CI, 1 to 28 more cases) with moderate certainty evidence 1
• Gastrointestinal bleeding: 13 additional cases per 1000 patients (95% CI, 3 to 23 more cases) with low certainty evidence 1

Duration Thresholds and Risk Stratification

Courses lasting less than 2 weeks are very unlikely to cause long-term side effects in adolescents. 2 The FDA label emphasizes that complications are dependent on both dose size and treatment duration, requiring risk-benefit assessment for each case. 3

Critical threshold: Adolescents requiring corticosteroids for more than 2 weeks warrant specialist referral and a structured tapering plan to prevent adrenal suppression and insufficiency. 2

Dosing Principles

The FDA mandates using the lowest possible dose to control the condition, with gradual dose reduction when feasible. 3 Since complications depend on both dose magnitude and duration, minimize both parameters whenever clinically appropriate. 3

For adolescents with significant obesity, base dosing on ideal body weight rather than actual weight to avoid unnecessary steroid exposure. 4 Consider a maximum daily dose of 80 mg prednisone in this population. 4

Monitoring Requirements During Treatment

For short courses (≤2 weeks):

• Monitor for hyperglycemia, particularly in at-risk patients 1
• Assess sleep quality and behavioral changes 1
• Watch for gastrointestinal symptoms suggesting bleeding 1

If steroid therapy extends beyond 6 weeks, intraocular pressure monitoring becomes mandatory. 3 The FDA label specifies that elevated intraocular pressure may develop in some individuals with prolonged use. 3

Adrenal Suppression Considerations

Drug-induced secondary adrenocortical insufficiency may persist for up to 12 months after discontinuing large doses given for prolonged periods. 3 During this recovery period, hormone therapy should be reinstituted during any stressful situation (illness, surgery, trauma). 3

For single short courses in adolescents:

• Adrenal suppression is minimal with courses <2 weeks 2
• No tapering required for courses <2 weeks 2
• Recovery of hypothalamic-pituitary-adrenal axis function is rapid 5

Growth Impact

Short courses (<2 weeks) have negligible impact on linear growth in adolescents. 2 However, the FDA notes that pediatric patients treated with corticosteroids may experience decreased growth velocity even at low systemic doses and without laboratory evidence of HPA axis suppression. 3

Therapy during puberty has the greatest potential to produce permanent loss of ultimate height. 5 This makes minimizing exposure particularly important in adolescents undergoing their growth spurt.

Common Pitfalls to Avoid

• Failing to provide emergency instructions: Patients on courses >2 weeks should receive written instructions for stress-dose corticosteroids and wear medical identification indicating corticosteroid use 5
• Abrupt discontinuation: Patients must be warned never to stop corticosteroids abruptly without medical supervision, as prolonged use causes adrenal dependence 3
• Ignoring infection risk: Adolescents should be advised of increased susceptibility to infections, especially varicella (chickenpox) 6
• Concurrent live vaccines: Routine vaccination should be deferred until corticosteroid therapy is discontinued when possible, as corticosteroids may potentiate replication of organisms in live attenuated vaccines 3

Patient Counseling Points

Before initiating corticosteroids, discuss with the adolescent and family:

• Not to stop taking corticosteroids suddenly 6
• To seek medical attention if they become unwell 6
• Increased infection susceptibility 6
• Potential for sleep disturbances and mood changes 1
• Need to carry steroid treatment card for courses >2 weeks 6