From the Guidelines
Prolonged use of corticosteroids is associated with numerous severe side effects, including increased infection risk, osteoporosis, suppression of the hypothalamic-pituitary-adrenal axis, diabetes, weight gain, and cardiovascular disease, highlighting the need for cautious and limited use of these medications. The negatives of corticosteroids are multifaceted, affecting various bodily systems and increasing the risk of serious complications. According to the British Society of Gastroenterology consensus guidelines on the management of inflammatory bowel disease in adults 1, steroid dependency and excess are significant concerns, with 14.9% of IBD patients in the UK experiencing these issues.
Key side effects and complications of long-term corticosteroid use include:
- Increased infection risk
- Osteoporosis
- Suppression of the hypothalamic-pituitary-adrenal axis
- Diabetes
- Weight gain
- Cardiovascular disease These side effects are not only detrimental to the patient's quality of life but also contribute to increased morbidity and mortality, as evidenced by a study showing that prolonged steroid use carries greater mortality compared with patients starting anti-TNF therapy 1.
The definition of steroid dependency and excess, as outlined in the guidelines, further emphasizes the need for careful management and monitoring of corticosteroid use 1. Steroid dependency is defined as an inability to wean below 10 mg of prednisolone or 3 mg of budesonide within 3 months of starting, or disease flare within 3 months of stopping steroids, while steroid excess is considered to be two or more courses of steroid over 1 year.
Given the significant negatives associated with corticosteroids, it is crucial to use these medications judiciously, at the lowest effective dose, and for the shortest duration possible, to minimize the risk of side effects and complications. This approach is supported by the guidelines and is essential for optimizing patient outcomes and reducing the risk of long-term morbidity and mortality 1.
From the FDA Drug Label
Signs of peritoneal irritation following gastrointestinal perforation in patients receiving corticosteroids may be minimal or absent. Musculoskeletal Corticosteroids decrease bone formation and increase bone resorption both through their effect on calcium regulation (i.e., decreasing absorption and increasing excretion) and inhibition of osteoblast function. Psychiatric derangements may appear when corticosteroids are used, ranging from euphoria, insomnia, mood swings, personality changes, and severe depression, to frank psychotic manifestations. Ophthalmic Intraocular pressure may become elevated in some individuals If steroid therapy is continued for more 6 weeks, intraocular pressure should be monitored. Patients should be warned not to discontinue the use of corticosteroids abruptly or without medical supervision As prolonged use may cause adrenal insufficiency and make patients dependent on corticosteroids, they should advise any medical attendants that they are taking corticosteroids and they should seek medical advice at once should they develop an acute illness including fever or other signs of infection Following prolonged therapy, withdrawal of corticosteroids may result in symptoms of the corticosteroid withdrawal syndrome including, myalgia, arthralgia, and malaise. Vaccines Patients on corticosteroid therapy may exhibit a diminished response to toxoids and live or inactivated vaccines due to inhibition of antibody response. Pregnancy Teratogenic Effects Pregnancy Category C Corticosteroids have been shown to be teratogenic in many species when given in doses equivalent to the human dose Systemically administered corticosteroids appear in human milk and could suppress growth, interfere with endogenous corticosteroid production, or cause other untoward effects Pediatric patients who are treated with corticosteroids by any route, including systemically administered corticosteroids, may experience a decrease in their growth velocity.
The negatives of corticosteroids include:
- Musculoskeletal effects: decreased bone formation, increased bone resorption, and inhibition of osteoblast function, which may lead to osteoporosis and growth inhibition in pediatric patients.
- Psychiatric effects: derangements, including euphoria, insomnia, mood swings, personality changes, severe depression, and frank psychotic manifestations.
- Ophthalmic effects: elevated intraocular pressure.
- Adrenal insufficiency: prolonged use may cause dependence on corticosteroids and adrenal insufficiency.
- Withdrawal syndrome: symptoms, including myalgia, arthralgia, and malaise, may occur after prolonged therapy.
- Vaccine response: diminished response to toxoids and live or inactivated vaccines.
- Teratogenic effects: corticosteroids have been shown to be teratogenic in many species.
- Effects on nursing infants: systemically administered corticosteroids appear in human milk and may suppress growth or cause other untoward effects.
- Growth effects: pediatric patients may experience a decrease in growth velocity. 2, 2, 2
From the Research
Negatives of Corticosteroids
- Corticosteroid-induced osteoporosis is a significant cause of morbidity in both men and women, and long-term use of even low-dose corticosteroids has been associated with increased risk of bone loss 3, 4
- The use of corticosteroids can lead to secondary adrenal insufficiency, which can be life-threatening in the event of an adrenal crisis 5, 6
- Long-term corticosteroid exposure is associated with various adverse events, including:
- The risk of adrenal insufficiency varies according to the route of administration, disease, treatment dose, and duration, with higher doses and longer use giving the highest risk 6
- The economic impact of long-term corticosteroid use is significant, with dose-related increases in health care resource utilization and costs 7