What are the effects of intravenous (IV) steroids on blood pressure (BP) in patients with pre-existing hypertension or cardiovascular disease?

Effects of IV Steroids on Blood Pressure

Intravenous steroids elevate blood pressure through multiple mechanisms and should be used with heightened caution in patients with pre-existing hypertension or cardiovascular disease, as systemic corticosteroids are recognized as blood pressure-elevating agents by major hypertension guidelines. 1

Mechanisms of Blood Pressure Elevation

IV steroids raise blood pressure through several distinct pathways:

• Volume expansion: ACTH and corticosteroids increase cardiac output, plasma volume, extracellular fluid volume, and exchangeable sodium, even at doses as low as 50 micrograms/day by constant IV infusion 2

• Enhanced pressor responsiveness: Cortisol increases vascular responsiveness to endogenous and exogenous catecholamines without increasing sympathetic nervous activity 2

• Non-mineralocorticoid mechanisms: Synthetic steroids (methylprednisolone, dexamethasone, prednisolone) raise blood pressure independent of plasma volume expansion or sodium retention, suggesting a distinct hypertensinogenic mechanism 2

Clinical Evidence in Specific Populations

Patients with Bullous Pemphigoid

High-dose IV methylprednisolone (1 gram daily or 15 mg/kg daily for 3 days) in patients with severe bullous pemphigoid—many with significant cardiovascular comorbidity—resulted in rapid clinical response but notable mortality 1:

• One patient died within 1 week of IV methylprednisolone
• Three additional patients died between 1-4 months post-treatment from cardiac arrest, infection, and congestive heart failure 1

Pediatric Patients with Chronic Lung Disease

Infants with chronic lung disease of infancy receiving steroids developed systemic hypertension at a mean age of 4.8 months, with 43% of patients affected 1:

• Hypertension was usually transient, lasting a mean of 3.7 months 1
• Approximately 50% required antihypertensive therapy 1
• Decreasing steroid dose, changing to nebulized administration, or discontinuation should be considered when hypertension develops 1

Paradoxical Hypertension During Steroid Reduction

A critical and often overlooked phenomenon: Nine young patients (ages 9-16) with steroid-requiring asthma developed hypertension specifically during corticosteroid reduction, not during maximum therapy 3:

• Diastolic pressures were normal (50-84 mmHg) during maximum corticosteroid therapy (1-4 mg/kg/day) 3
• Maximum diastolic pressures reached 100-120 mmHg occurring 1-8 weeks after steroid reduction began 3
• All six tested patients had elevated renin levels, and five had elevated aldosterone 3
• Hypertension was resistant to diuretics but responded rapidly to ACE inhibitors 3

Guideline Recognition

Major hypertension guidelines explicitly list systemic corticosteroids as blood pressure-elevating medications 1:

• The 2017 ACC/AHA guidelines list dexamethasone, fludrocortisone, methylprednisolone, prednisone, and prednisolone as agents that may cause elevated blood pressure 1
• The 2020 ISH guidelines categorize steroids under "Other medications" that increase blood pressure 1
• The 2024 ESC guidelines recommend screening all hypertensive patients for substances that may increase blood pressure or interfere with antihypertensive medications 1

Clinical Management Algorithm

For patients requiring IV steroids with pre-existing hypertension or cardiovascular disease:

1. Pre-treatment assessment: Measure baseline blood pressure and document cardiovascular comorbidities 1

2. During IV steroid administration:

   • Monitor blood pressure closely during and immediately after IV steroid pulses 1
   • Be vigilant for signs of volume overload and cardiac decompensation 1, 2
   • Consider prophylactic adjustment of antihypertensive regimen in high-risk patients 1

3. During steroid taper:

   • Critical period: Monitor blood pressure closely for 1-8 weeks after beginning steroid reduction 3
   • Check renin and aldosterone levels if hypertension develops during taper 3
   • If hypertension occurs during taper, initiate ACE inhibitor rather than diuretic therapy 3

4. Ongoing management:

   • Treat blood pressure to target regardless of steroid requirement if steroids cannot be discontinued 1
   • Consider mineralocorticoid receptor antagonists if aldosterone excess is documented 3

Common Pitfalls

• Assuming blood pressure will normalize immediately after stopping steroids: Hypertension may paradoxically worsen during steroid reduction and persist for months 3

• Using diuretics as first-line therapy for steroid-induced hypertension during taper: This approach was ineffective in patients with elevated renin-aldosterone; ACE inhibitors were superior 3

• Underestimating cardiovascular risk in elderly patients with multiple comorbidities: High-dose IV steroids carried significant mortality risk in this population 1

• Failing to monitor blood pressure in pediatric patients: Systemic hypertension developed in 43% of infants with chronic lung disease receiving steroids 1