When should corticosteroids (e.g. prednisolone) be avoided or used with caution in elderly patients?

When to Avoid or Use Corticosteroids with Caution in Elderly Patients

Systemic corticosteroids should be avoided or limited when possible in elderly patients, with topical or inhaled formulations preferred when feasible, and when systemic therapy is necessary, use the lowest effective dose for the shortest duration with mandatory bone protection and monitoring for cardiovascular, metabolic, and infectious complications. 1, 2, 3

Absolute and Relative Contraindications

High-Risk Clinical Scenarios Requiring Avoidance

• Uncontrolled hypertension or heart failure: Systemic corticosteroids cause sodium retention and can precipitate or worsen cardiovascular complications, which elderly patients are particularly vulnerable to 1, 4

• Active or recent serious infection: Elderly patients on corticosteroids have significantly increased infection risk, with current doses having the greatest impact but cumulative exposure over 2-3 years also contributing 5, 3

• Uncontrolled diabetes mellitus: Corticosteroids cause hyperglycemia and insulin resistance, with elderly patients at higher risk for developing steroid-induced diabetes 4, 6

• Severe osteoporosis without bone protection: Elderly patients have the highest incidence of corticosteroid-induced osteoporosis and fractures, with doses ≥7.5 mg/day prednisolone increasing fracture risk even with higher baseline bone density 1, 4

• Active peptic ulcer disease: Risk of gastrointestinal bleeding and perforation is elevated, especially when combined with NSAIDs, which is common in elderly patients 1, 4

Conditions Requiring Extreme Caution

• Frailty or advanced age (>65 years): The European Hematology Association recommends minimizing steroid exposure in older patients due to increased risk of severe complications including muscle weakness, atrophy, and infections 3, 6

• Renal or hepatic impairment: Elderly patients have higher prednisolone plasma concentrations due to reduced clearance, though dosing adjustments remain controversial 4

• Glaucoma or cataracts: Regular ophthalmologic monitoring is mandatory as elderly patients are at increased risk 4, 6

• Psychiatric history: Corticosteroids can precipitate mood disturbances and psychosis, requiring careful monitoring 4, 6

Specific Clinical Contexts

Inflammatory Bowel Disease

• Never use systemic corticosteroids for maintenance therapy in elderly IBD patients—this is explicitly contraindicated due to lack of efficacy in preventing relapse and high risk of adverse effects 1, 2

• Steroid dependency (inability to wean below 10 mg prednisolone within 3 months) or steroid excess (≥2 courses per year) is associated with increased mortality, particularly in elderly patients 1

• Budesonide is strongly preferred over prednisolone for ileocolonic Crohn's disease or left-sided ulcerative colitis in elderly patients due to better safety profile 2, 3

• Prolonged use (>3 months) or doses >20 mg prednisolone for >6 weeks increases surgical complications five-fold if surgery becomes necessary 1

Perioperative Setting

• Avoid elective surgery requiring corticosteroids >20 mg prednisolone for >6 weeks due to five-fold increased infectious complications 1

• If weaning is not possible before surgery, postpone elective procedures 1

• Taper steroids slowly post-operatively (1 mg/week if used >6 months) to avoid Addisonian crisis, which presents as hypotension, hyponatremia, and hypoglycemia 1

Dose-Related Risk Thresholds

Critical Dosing Considerations

• Doses ≥30 mg/day prednisolone for ≥30 days or cumulative ≥5 g over 1 year represent very high fracture risk requiring immediate bone protection with PTH/PTHrP preferred over bisphosphonates 1, 7

• Doses ≥20 mg/day for ≥4 weeks require Pneumocystis jirovecii pneumonia prophylaxis with trimethoprim-sulfamethoxazole 7

• Doses ≥7.5 mg/day chronically are associated with increased vertebral and nonvertebral fractures in elderly patients 4

• The incidence of complications in elderly patients is dose-related, with osteoporosis (16%) and hypertension (12%) being most common 8

Mandatory Monitoring and Prevention

Before Initiating Therapy

• Assess hepatic and renal function 2
• Screen for active infections, tuberculosis exposure, and update vaccinations (pneumococcal, influenza, hepatitis B, herpes zoster) 7
• Obtain baseline bone mineral density, blood pressure, fasting glucose, and potassium 7, 4
• Evaluate cardiovascular risk factors including hyperlipidemia 1

During Therapy

• Monitor blood pressure, glucose, and potassium regularly as elderly patients are at highest risk for hypertension, diabetes, and hypokalemic alkalosis 7, 4

• Repeat bone densitometry at 1 year, then every 2-3 years if stable or annually if declining 7

• Screen for sleep disturbances, mood changes, gastric irritation, glaucoma, and muscle weakness 2, 6

• Assess for signs of infection vigilantly, as infection risk increases by 30% with 5 mg prednisolone for 3 months, 46% for 6 months, and 100% for 3 years of continuous use 5

Required Prophylactic Measures

Universal for All Elderly Patients on Corticosteroids

• Calcium 1000 mg daily and vitamin D 800 IU daily are mandatory for all patients 7, 1

• Proton pump inhibitor or H2-receptor antagonist for gastrointestinal protection, especially critical if combined with NSAIDs 7, 1

Bone Protection Based on Risk Stratification

• Oral bisphosphonates strongly recommended for adults ≥40 years with T-score ≤-1.5 or FRAX 10-year risk ≥20% for major osteoporotic fracture 7, 1

• PTH/PTHrP conditionally recommended over bisphosphonates for very high-risk patients (≥30 mg/day prednisolone for ≥30 days or cumulative ≥5 g/year) 1, 7

• Intravenous zoledronic acid for malabsorption, oral bisphosphonate intolerance, or fracture despite oral therapy 7

• Co-administration of bisphosphonates retards bone loss in elderly corticosteroid-treated patients and is recommended for prevention and treatment 4

Preferred Alternatives in Elderly Patients

Route and Formulation Selection

• Topical or inhaled corticosteroids with better safety profiles should be first-line when appropriate for the condition 3, 2

• For distal colonic disease, low-volume topical formulations are preferred in elderly patients with limited mobility or weak sphincter tone 2

• Budesonide formulations are preferred over conventional systemic corticosteroids for appropriate indications due to reduced systemic absorption 2, 3

Steroid-Sparing Strategies

• Consider anti-TNF therapy or other immunomodulators early rather than prolonged corticosteroid use, as prolonged steroids carry greater mortality than anti-TNF therapy in IBD patients 1

• In rheumatoid arthritis, low-dose prednisolone (5 mg) for up to 2 years can be effective with acceptable safety in elderly patients when combined with disease-modifying drugs 9

Critical Pitfalls to Avoid

• Never abruptly discontinue corticosteroids after prolonged use (>3 months) due to risk of Addisonian crisis; taper slowly based on duration of therapy 1, 7

• Do not delay bone protection measures—fracture risk increases within 3 months of starting corticosteroids, with greatest bone loss occurring early in treatment 7, 4

• Avoid combining with NSAIDs without gastrointestinal prophylaxis, as this significantly increases bleeding risk in elderly patients 1

• Do not use raloxifene or romosozumab for osteoporosis prevention except in patients intolerant of all other options, due to risks of thromboembolism, fatal stroke, and cardiovascular events 1, 7

• Recognize that elderly patients may have higher unbound prednisolone concentrations due to age-related pharmacokinetic changes, though routine dose reduction is not clearly indicated 4