When should steroids be used in medical treatment?

When to Use Steroids in Medical Treatment

Steroids should be used when there is clear evidence of benefit for specific conditions—primarily severe inflammatory diseases, autoimmune disorders, and life-threatening situations—but should be avoided for empiric use without a definitive diagnosis due to significant risks and limited evidence of benefit in many conditions.

Disease-Specific Indications with Strong Evidence

Severe Alcoholic Hepatitis

• Use prednisolone 40 mg/day for 4 weeks then taper over 2-4 weeks in patients with Maddrey Discriminant Function (MDF) score ≥32, which provides a 30% relative risk reduction in mortality and a number needed to treat of 5 1
• Avoid steroids if MDF >54, as mortality risk from steroid use exceeds benefit at this threshold 1
• Exclude patients with concomitant pancreatitis, gastrointestinal bleeding, renal failure, or active infection, as efficacy has not been established in these populations 1

Adult-Onset Still's Disease (AOSD)

• Most patients (88%) will require corticosteroids at some point in their disease course, with response rates of 76-95% 1
• Reserve large doses of prednisone (limited to 6 months) for NSAID-refractory systemic disease presenting with persistent anemia, pericarditis, serositis, and elevated liver enzymes 1
• NSAID monotherapy controls disease in only 7-15% of patients, making steroids necessary for the majority 1

Bullous Pemphigoid

• For moderate-to-severe disease, use systemic corticosteroids 0.5-1.0 mg/kg daily with weaning dose once control is achieved (strength of recommendation A) 1
• Very potent topical steroids (5-15 g twice daily to whole skin surface) are an alternative if patient or carer is capable of application 1

Immune Thrombocytopenia (ITP)

• In adults with newly diagnosed ITP and platelet count <30 × 10⁹/L who are asymptomatic or have minor mucocutaneous bleeding, use corticosteroids rather than observation 1
• In adults with platelet count ≥30 × 10⁹/L who are asymptomatic or have minor mucocutaneous bleeding, do NOT use corticosteroids—manage with observation instead (strong recommendation) 1
• Monitor closely for hypertension, hyperglycemia, sleep and mood disturbances, gastric irritation, glaucoma, myopathy, and osteoporosis during treatment 1

Conditions Where Steroids Should NOT Be Used

Dysphonia/Hoarseness

• Do not use steroids empirically for hoarseness due to significant risk profile and limited evidence of benefit 1
• Steroids should only be used when diagnosis is known and treatment is targeted, after shared decision-making about risks and limited benefits 1

Degenerative Cervical Spondylosis

• Systemic glucocorticoids are not supported by evidence for axial cervical spondylotic disease and have no demonstrated benefit for mechanical neck pain or myelopathy 2
• Intra-articular facet joint steroid injections are explicitly recommended against for chronic pain from degenerative spinal disease 2

Acute Laryngitis/Upper Respiratory Infections

• Do not routinely use antibiotics or steroids for dysphonia, as most cases are viral and self-limited within 7-10 days 1

SARS (Severe Acute Respiratory Syndrome)

• Corticosteroids are not indicated for routine care of patients with uncomplicated SARS 1
• Pulse-dose steroid therapy could be considered only for patients with clinical deterioration (persistent fever, worsening radiographic opacities, hypoxemic respiratory failure), but decision must weigh benefits against risks 1

Perioperative Steroid Management

Preoperative Considerations

• For elective surgery, stop corticosteroids or minimize dose wherever possible to reduce risk of postoperative infectious complications, VTE, and anastomotic leak 1, 3
• Risks are greatest for those taking high-dose steroids (≥40 mg prednisolone) 1
• Avoid corticosteroid injections for at least 3 months preceding joint replacement surgery 3

Intraoperative Management

• Patients on oral corticosteroids for >4 weeks prior to surgery should receive equivalent intravenous hydrocortisone while nil by mouth 1, 3
• Prednisolone 5 mg = hydrocortisone 20 mg = methylprednisolone 4 mg 1, 3
• There is no value in increasing steroid dosage to cover stress in the perioperative period 1

Postoperative Management

• Avoid inappropriate prolongation of steroids after surgery—implement standardized steroid-taper protocols based on preoperative dose and duration 1, 3
• Monitor for wound healing complications, infection, and adrenal insufficiency 3

Dosing Principles and Formulations

Potency Hierarchy

• Short-acting (least potent): Hydrocortisone 4
• Intermediate-acting (4-5× more potent): Prednisone, methylprednisolone 4
• Long-acting (25× more potent): Dexamethasone 4

Alternate-Day Therapy

• Use short-acting corticosteroids (prednisone, prednisolone, methylprednisolone, hydrocortisone) for alternate-day therapy to minimize HPA axis suppression 5
• Avoid dexamethasone and betamethasone for alternate-day therapy due to prolonged suppressive effect 5
• Administer corticosteroids in the morning (between 2 am and 8 am) when adrenal cortex activity is maximal to minimize suppression 5
• Keep initial suppressive dose period as brief as possible (usually 4-10 days for allergic and collagen diseases) before transitioning to alternate-day therapy 5

Critical Monitoring Requirements

During Treatment

• Monitor for hypertension, hyperglycemia, sleep and mood disturbances, gastric irritation/ulcer formation, glaucoma, myopathy, and osteoporosis regardless of steroid type or duration 1
• Conduct assessment of health-related quality of life (HRQoL) including depression, fatigue, and mental status while patients receive corticosteroids 1

Long-Term Complications

• Documented side effects include lipodystrophy, cardiovascular disease, cerebrovascular disease, osteoporosis, impaired wound healing, cataracts, peptic ulcers, infection, mood disorders, avascular necrosis, pancreatitis, and diabetogenesis 1

Common Pitfalls to Avoid

• Never use steroids empirically without a definitive diagnosis—the significant risk profile demands targeted use 1
• Do not continue steroids longer than necessary—establish clear tapering protocols from the outset 1, 5
• Avoid using long-acting steroids (dexamethasone) when alternate-day therapy is planned—use short-acting agents instead 5
• Do not assume all inflammatory conditions benefit from steroids—many lack evidence of efficacy (e.g., mechanical neck pain, uncomplicated viral infections) 1, 2
• Remember that steroid-resistant patients exist—humans are a "steroid-resistant" species compared to other animals, and individual responses vary 6