How to manage a wired feeling caused by intramuscular (IM) corticosteroids?

Managing the "Wired" Feeling from IM Corticosteroids

The wired feeling from IM corticosteroids is a dose-dependent psychiatric side effect that typically occurs during the first few weeks of therapy and is best managed through reassurance, symptomatic treatment with sedatives or mood stabilizers if severe, and avoidance of IM formulations in favor of oral alternatives when possible. 1, 2

Understanding the Problem

The hyperarousal or "wired" sensation you're experiencing represents corticosteroid-induced psychiatric symptoms, which are extremely common and generally mild but distressing side effects. 1

• Hypomania and mania are the most common acute mood changes during corticosteroid therapy, manifesting as irritability, insomnia, restlessness, and the sensation of being "wired." 2
• These symptoms are dose-dependent and typically emerge within the first few weeks of starting therapy. 1, 2
• The symptoms are generally reversible with dose reduction or discontinuation. 2

Immediate Management Strategies

Non-Pharmacologic Approaches

• Reassurance is critical: Explain to the patient that these symptoms are expected, common, dose-dependent, and will resolve when the corticosteroid is discontinued or tapered. 1
• Avoid stimulants: Eliminate caffeine, energy drinks, and other stimulants that can exacerbate the hyperarousal. 3
• Sleep hygiene: Implement strict sleep routines, though recognize that insomnia is a direct corticosteroid effect. 4

Pharmacologic Management for Severe Symptoms

If the wired feeling is significantly impairing function or causing severe insomnia:

• Lithium has the strongest evidence for preventing and treating corticosteroid-induced mood symptoms, based on controlled trials. 2
• Antipsychotic medications (particularly newer atypical antipsychotics) can be useful for normalizing acute mood changes, though evidence comes from uncontrolled trials. 2
• Anti-seizure medications such as phenytoin (controlled trial evidence) or lamotrigine may help, with lamotrigine also potentially reversing cognitive effects. 2
• Short-term benzodiazepines can provide symptomatic relief for insomnia and anxiety, though this is based on clinical practice rather than formal studies. 1

Preventing Future Episodes

Avoid IM Corticosteroids When Possible

The ARIA guidelines strongly recommend against using intramuscular corticosteroids due to the risk of serious side effects that may be far more problematic than the condition being treated. 4

• IM formulations deliver a large, sustained dose that cannot be adjusted once administered, increasing the risk and duration of psychiatric side effects. 4
• Oral corticosteroids are preferred because they allow for dose titration and earlier discontinuation if side effects become intolerable. 4

Dose and Duration Considerations

• Use the minimum effective dose to control the underlying condition, as psychiatric symptoms are dose-dependent. 3, 1
• Single morning dosing may help minimize sleep disturbance compared to divided doses or evening administration. 3
• Short courses (less than 3-4 weeks) can be stopped abruptly without tapering, which may shorten the duration of psychiatric symptoms. 5

Common Pitfalls to Avoid

• Do not abruptly stop corticosteroids if the patient has been on therapy for more than 3 weeks or at doses above 7.5 mg prednisolone equivalent daily, as this risks adrenal insufficiency. 5
• Do not dismiss the patient's symptoms as trivial—while generally mild, corticosteroid-induced psychiatric changes can occasionally be severe and warrant intervention. 1
• Do not assume all patients will experience these symptoms—they are common but not universal, and risk factors beyond dose are poorly characterized. 2

Timeline and Prognosis

• Psychiatric symptoms typically emerge within the first few weeks of therapy. 1, 2
• Symptoms are generally reversible with dose reduction or discontinuation. 2
• For IM formulations, symptoms will persist until the depot is metabolized, which may take several weeks depending on the specific formulation used. 4

When to Seek Additional Help

Consider psychiatric consultation if:

• Symptoms are severe enough to impair daily function
• The patient develops frank psychosis or severe mania
• The underlying condition requires continued high-dose corticosteroid therapy, necessitating prophylactic mood stabilization 2