Give a case scenario of a steroid‑related adverse event (other than hyperglycaemia) in a 73‑year‑old woman with severe chronic obstructive pulmonary disease and longstanding rheumatoid arthritis on chronic oral prednisone who is admitted to the ICU for an acute COPD exacerbation.

Case Scenario: Steroid-Induced Osteoporotic Vertebral Compression Fracture

A 73-year-old woman with severe COPD and longstanding rheumatoid arthritis on chronic oral prednisone 10 mg daily for 3 years presents to the ICU with acute COPD exacerbation requiring mechanical ventilation. On day 4 of her ICU stay, while being repositioned in bed, she experiences sudden severe mid-thoracic back pain. Imaging reveals an acute T8 vertebral compression fracture—a direct consequence of chronic corticosteroid-induced osteoporosis compounded by acute high-dose steroid therapy for her exacerbation.

Clinical Context and Mechanism

This scenario illustrates a critical steroid-related adverse event beyond hyperglycemia that significantly impacts morbidity and quality of life:

• Chronic low-dose corticosteroid exposure (≤10 mg/day prednisone) causes osteoporosis as a common adverse effect, occurring frequently enough to warrant concern in long-term users 1
• Acute exacerbation treatment with systemic corticosteroids (typically prednisone 30-40 mg daily for 5-7 days) 2, 3 adds a second insult to already compromised bone integrity
• Vertebral compression fractures represent a devastating complication that severely impairs quality of life through chronic pain, reduced mobility, and increased mortality risk

Why This Patient Is at Extreme Risk

Baseline Vulnerability Factors

• Longstanding rheumatoid arthritis itself increases fracture risk through inflammatory bone loss 1
• Chronic prednisone therapy for 3 years causes progressive bone mineral density loss, with osteoporosis and steroid-myopathy appearing in some patients even at low doses 1
• Advanced age (73 years) compounds fracture risk exponentially
• Severe COPD limits mobility and weight-bearing exercise, further accelerating bone loss

Acute Precipitating Factors

• ICU admission with mechanical ventilation requires immobilization, causing rapid bone turnover
• Acute high-dose corticosteroid therapy for COPD exacerbation (standard treatment per guidelines 4) acutely worsens bone fragility
• Physical manipulation during repositioning provides the mechanical stress that precipitates fracture in severely osteoporotic bone

The Steroid Dosing Dilemma in This Case

What Guidelines Recommend for COPD Exacerbation

• Systemic corticosteroids are mandatory for severe COPD exacerbations requiring ICU admission, as they reduce treatment failure by over 50% and shorten hospital stay 5, 6
• Standard dosing: prednisone 30-40 mg daily (or IV hydrocortisone 100 mg every 6 hours if unable to take oral) for 5-7 days 2, 3, 7
• Duration should not exceed 7 days as longer courses increase adverse effects without additional benefit 2, 3, 7

The Compounding Effect in Chronic Users

• This patient's baseline prednisone 10 mg daily for rheumatoid arthritis already causes cutaneous atrophy, cataracts, glaucoma, osteoporosis, and steroid-myopathy 1
• Adding acute high-dose therapy (30-40 mg daily) represents a 4-fold dose increase superimposed on chronically compromised bone
• No evidence supports withholding steroids for COPD exacerbation even in high-risk patients, as mortality benefits outweigh risks 5, 8, 6

Clinical Presentation of the Fracture

• Sudden severe mid-thoracic back pain during routine repositioning in bed
• Pain exacerbated by movement and deep breathing
• Possible neurological compromise if fracture fragments impinge on spinal cord (rare but catastrophic)
• Immediate impact on quality of life: inability to mobilize, prolonged ICU stay, chronic pain syndrome

Why This Adverse Event Matters More Than Hyperglycemia

Morbidity Impact

• Hyperglycemia is common (occurs in 15% of steroid-treated COPD patients 5 to 49.5% in ICU patients 8) but is reversible and manageable with insulin
• Vertebral compression fractures cause permanent disability, chronic pain, kyphosis, reduced lung capacity (worsening COPD), and loss of independence 1

Mortality Impact

• Hyperglycemia increases infection risk but rarely causes direct mortality in monitored ICU settings
• Vertebral fractures increase 1-year mortality by 20-30% through immobility complications (pneumonia, thromboembolism, deconditioning)

Quality of Life Impact

• Hyperglycemia requires temporary insulin therapy during hospitalization
• Vertebral fractures result in chronic pain requiring opioids, loss of height, restrictive lung disease (devastating in COPD), inability to perform activities of daily living, and social isolation

Prevention Strategies That Were Missed

Before ICU Admission

• Bone density screening should have been performed after 3 years of chronic prednisone therapy 1
• Prophylactic bisphosphonate therapy (alendronate or risedronate) should have been initiated when chronic corticosteroids began
• Calcium 1200-1500 mg daily plus vitamin D 800-1000 IU should have been prescribed 1
• Fall risk assessment and home safety evaluation for elderly patients on chronic steroids

During ICU Stay

• Minimize mechanical stress during repositioning (use lift sheets, adequate staff, gentle technique)
• Consider prophylactic vertebroplasty consultation in patients with known severe osteoporosis requiring prolonged immobilization
• Shortest effective steroid duration (5 days rather than 7-14 days) to minimize cumulative bone toxicity 2, 3, 7

Management After Fracture Occurs

Acute Management

• Pain control with multimodal analgesia (avoid excessive opioids that worsen respiratory depression in COPD)
• Imaging (MRI preferred over CT) to assess fracture stability and rule out spinal cord compression
• Orthopedic/spine surgery consultation for consideration of vertebroplasty or kyphoplasty if pain is refractory
• Continue COPD exacerbation treatment as fracture does not change indication for steroids 2, 3

Long-Term Implications

• Chronic pain syndrome requiring ongoing pain management
• Increased risk of subsequent fractures (hip, additional vertebrae)
• Worsened COPD due to restrictive chest wall mechanics from kyphosis
• Prolonged rehabilitation and possible permanent loss of independence
• Psychological impact of sudden disability and loss of function

The Critical Teaching Point

This case demonstrates that while hyperglycemia is the most frequent steroid complication (occurring in 15-50% of patients 5, 8), osteoporotic fractures represent a far more devastating adverse event in terms of permanent morbidity, mortality, and quality of life destruction. The fracture was entirely predictable and potentially preventable through proper bone health management in a patient on chronic corticosteroids, yet the acute COPD exacerbation still mandated steroid therapy despite the known risks 4, 2, 3.

Algorithm for Steroid Decision-Making in High-Risk Patients

1. Assess fracture risk before prescribing chronic steroids: age >65, prior fracture, family history, low BMI, smoking, alcohol use 1
2. Initiate bone protection immediately when starting chronic steroids: bisphosphonate + calcium + vitamin D 1
3. When acute exacerbation requires additional steroids: use minimum effective dose (prednisone 30-40 mg) for minimum duration (5 days, not 7-14 days) 2, 3, 7
4. During ICU stay: implement fracture prevention protocols (gentle repositioning, early mobilization when safe, avoid Valsalva maneuvers)
5. After discharge: aggressive bone health management, fall prevention, and close monitoring for new fractures