Do steroids cause diarrhea?

Do Steroids Cause Diarrhea?

Steroids do not directly cause diarrhea as a primary adverse effect; rather, diarrhea during steroid therapy typically represents either corticosteroid withdrawal syndrome mimicking the underlying disease, or is a symptom of the condition being treated. 1

Corticosteroid Withdrawal Syndrome

The most clinically relevant association between steroids and diarrhea occurs during steroid withdrawal, not during active treatment:

• Corticosteroid withdrawal syndrome presents with diarrhea, abdominal pain, nausea, vomiting, weakness, and fatigue—symptoms that can mimic the underlying inflammatory bowel disease being treated. 1
• This syndrome is under-recognized but occurs in approximately 50% of patients tested immediately after withdrawal of medium- or high-dose prednisolone used for long periods. 1
• This is a critical diagnostic pitfall: clinicians may mistake withdrawal symptoms for disease relapse and inappropriately escalate therapy rather than recognizing the withdrawal syndrome. 1

Steroids as Treatment for Diarrhea

Paradoxically, corticosteroids are actually first-line therapy for treating severe diarrhea in multiple clinical contexts:

Inflammatory Bowel Disease

• High-dose intravenous corticosteroids (methylprednisolone 60 mg daily or hydrocortisone 100 mg 6-hourly) are the cornerstone of treatment for acute severe ulcerative colitis with diarrhea. 1
• Intravenous prednisolone achieved a 73% clinical remission rate in patients with severe UC and diarrhea within 5 days of treatment. 1
• Corticosteroids are not effective for maintaining remission in Crohn's disease, though they effectively treat acute flares with diarrhea. 1

Immunotherapy-Related Colitis

• For grade 2 immune checkpoint inhibitor-related colitis with diarrhea, oral prednisone 1-2 mg/kg/day should be initiated immediately. 2
• For grade 3-4 immunotherapy-related colitis, IV methylprednisolone 1-2 mg/kg/day is recommended as first-line therapy. 1, 2, 3
• Steroids should be continued until symptoms improve to grade ≤1, then tapered over 4-6 weeks. 1, 2

Chemotherapy-Related Diarrhea

• IV methylprednisolone can effectively treat chemotherapy-related diarrhea refractory to standard antidiarrheal agents (loperamide, diphenoxylate-atropine, octreotide). 4

Mechanism of Anti-Diarrheal Effect

Corticosteroids suppress diarrhea through multiple anti-inflammatory mechanisms: induction of T-cell apoptosis, suppression of interleukin transcription, suppression of arachidonic acid metabolism, and stimulation of lymphocyte apoptosis within the gut lamina propria. 3

Critical Pitfalls to Avoid

• Do not confuse corticosteroid withdrawal syndrome (which includes diarrhea) with disease relapse—this occurs in ~50% of patients stopping medium- or high-dose steroids. 1
• Methylprednisolone causes significantly less hypokalaemia than hydrocortisone at equivalent doses due to reduced mineralocorticoid effect, making it preferable for treating severe colitis. 1
• Long-duration steroid therapy (>30 days) without adding infliximab significantly increases infection risk in patients with steroid-refractory colitis. 1
• Steroids are not listed among the >700 drugs commonly implicated in causing drug-induced diarrhea. 5