What are the negative effects of corticosteroids (cortico-steroids)?

From the Guidelines

Corticosteroids have significant negative effects with long-term use, including increased infection risk, osteoporosis, suppression of the hypothalamic-pituitary-adrenal axis, diabetes, weight gain, and cardiovascular disease, which can lead to increased mortality in patients with inflammatory bowel disease (IBD) 1. The use of corticosteroids in IBD patients can lead to numerous side effects, particularly with prolonged use, defined as continuous therapy for more than 3 months. Some of the common side effects include:

• Increased infection risk
• Osteoporosis
• Suppression of the hypothalamic-pituitary-adrenal axis
• Diabetes
• Weight gain
• Cardiovascular disease These side effects can have a significant impact on the patient's quality of life and morbidity. Furthermore, there is evidence that prolonged steroid use can lead to increased mortality in IBD patients, with a study showing that patients on long-term steroids have a higher mortality rate compared to those starting anti-TNF therapy 1. It is essential to monitor patients on corticosteroids regularly to minimize the risk of these side effects. This includes monitoring blood pressure, blood sugar, bone density, and eye health. Additionally, doctors should prescribe the lowest effective dose for the shortest possible time and recommend a gradual tapering schedule when discontinuing treatment to avoid adrenal suppression and other complications. The definition of steroid dependency, which is 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, can help identify patients at risk of these negative effects 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 than 6 weeks, intraocular pressure should be monitored. Patients should be warned not to discontinue the use of corticosteroids abruptly or without medical supervision Following prolonged therapy, withdrawal of corticosteroids may result in symptoms of the corticosteroid withdrawal syndrome including, myalgia, arthralgia, and malaise. Pediatric patients who are treated with corticosteroids by any route, including systemically administered corticosteroids, may experience a decrease in their growth velocity. The linear growth of pediatric patients treated with corticosteroids should be monitored, and the potential growth effects of prolonged treatment should be weighed against clinical benefits obtained and the availability of treatment alternatives. In order to minimize the potential growth effects of corticosteroids, pediatric patients should be titrated to the lowest effective dose In particular, the increased risk of diabetes mellitus, fluid retention and hypertension in elderly patients treated with corticosteroids should be considered.

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.
• Withdrawal syndrome: symptoms including myalgia, arthralgia, and malaise after prolonged therapy.
• Growth effects: decrease in growth velocity in pediatric patients.
• Increased risk of diabetes mellitus, fluid retention, and hypertension in elderly patients. These negatives should be carefully considered and monitored when using corticosteroids, especially in pediatric and elderly patients 2, 2, 2.

From the Research

Negatives of Corticosteroids

• Adrenal insufficiency is a common negative effect of long-term corticosteroid use, as seen in a case study where a 71-year-old woman was diagnosed with secondary adrenal insufficiency after chronic corticosteroid treatment 3.
• The risk of adrenal insufficiency varies by route of administration, disease, treatment dose, and duration, with higher doses and longer use giving the highest risk 4.
• Long-term corticosteroid exposure is associated with various adverse events, including:
  • Hypertension (prevalence >30%) 5
  • Bone fracture (21%-30%) 5
  • Cataract (1%-3%) 5
  • Nausea, vomiting, and other gastrointestinal conditions (1%-5%) 5
  • Metabolic issues (eg, weight gain, hyperglycemia, and type 2 diabetes) 5
• Corticosteroids are also associated with complications such as:
  • Avascular necrosis 6
  • Gastrointestinal bleeding 6
  • Myocardial infarction 6
  • Heart failure 6
  • Cerebrovascular events 6
  • Diabetes mellitus 6
  • Psychiatric syndromes 6
  • Ophthalmic complications 6
  • Tuberculosis reactivation 6
  • Bacterial sepsis 6
• The economic impact of corticosteroid use is significant, with per-annum incremental costs relative to nonusers ranging from $5700 in low-dose users to $29,000 in high-dose users 5.
• The optimal strategy to ensure early identification and treatment of adrenal insufficiency and safe corticosteroid withdrawal in routine clinical practice remains to be defined 7.