What are the laboratory findings associated with long-term use of corticosteroids (steroids)?

From the Guidelines

Long-term steroid use requires regular laboratory monitoring to prevent and detect potential complications, and I recommend baseline labs before starting therapy and then periodic monitoring every 3-6 months. This monitoring should include a complete blood count, comprehensive metabolic panel (focusing on glucose, electrolytes, and liver function), lipid panel, and bone mineral density testing, as steroids can affect multiple body systems, including glucose metabolism, bone density, adrenal function, and electrolyte balance 1. For patients on prednisone or similar glucocorticoids, monitoring blood glucose is particularly important as steroid-induced hyperglycemia is common, and checking hemoglobin A1c every 3-6 months is recommended 1. Additionally, morning cortisol levels should be assessed to evaluate adrenal function, and vitamin D and calcium levels should be monitored to assess bone health, with a high-risk threshold for intervention being a T score of -1.5 or a FRAX 10-year 20% risk for major osteoporotic fracture 1. Patients on long-term steroids should also have regular blood pressure checks and eye examinations for glaucoma and cataracts, with the frequency of monitoring potentially increased in patients with pre-existing conditions like diabetes or osteoporosis 1. Early detection of abnormalities allows for timely intervention with medication adjustments or additional treatments to prevent serious complications, such as osteoporosis, which can be prevented with calcium and vitamin D supplements, and bisphosphonate therapy if necessary 1. It is also important to assess and modify risk factors for osteoporosis, including prolonged or high-dose steroid use, uncontrolled inflammation, weight loss, and lack of physical activity, and to consider alternative treatments, such as denosumab or teriparatide, for patients who are intolerant of bisphosphonates or have contraindications 1. Overall, regular monitoring and timely intervention are crucial to preventing and managing the potential complications of long-term steroid use, and to minimizing the risk of morbidity, mortality, and decreased quality of life.

From the FDA Drug Label

Growth and development of infants and children on prolonged corticosteroid therapy should be carefully observed. Special consideration should be given to patients at increased risk of osteoporosis (e.g., postmenopausal women) before initiating corticosteroid therapy. Inclusion of therapy for osteoporosis prevention or treatment should be considered. To minimize the risk of glucocortoicoid-induced bone loss, the smallest possible effective dosage and duration should be used. Lifestyle modification to reduce the risk of osteoporosis (e.g., cigarette smoking cessation, limitation of alcohol consumption, participation in weight-bearing exercise for 30-60 minutes daily) should be encouraged. Calcium and vitamin D supplementation, bisphosphonate (e.g., alendronate, risedronate), and a weight-bearing exercise program that maintains muscle mass are suitable first-line therapies aimed at reducing the risk of adverse bone effects Current recommendations suggest that all interventions be initiated in any patient in whom glucocorticoid therapy with at least the equivalent of 5 mg of prednisone for at least 3 months is anticipated; in addition, sex hormone replacement therapy (combined estrogen and progestin in women; testosterone in men) should be offered to such patients who are hypogonadal or in whom replacement is otherwise clinically indicated and biphosphonate therapy should be initiated (if not already) if bone mineral density (BMD) of the lumbar spine and/or hip is below normal

Long-term steroid use labs should include monitoring for:

• Osteoporosis: bone mineral density (BMD) of the lumbar spine and/or hip
• Adrenal insufficiency: monitoring for symptoms of corticosteroid withdrawal syndrome, including myalgia, arthralgia, and malaise
• Glucose levels: monitoring for increased blood glucose concentrations
• Electrolyte imbalance: monitoring for hypokalemia
• Liver function: monitoring for changes in liver enzymes
• Lipid profile: monitoring for changes in lipid levels
• Blood pressure: monitoring for hypertension
• Intraocular pressure: monitoring for elevated intraocular pressure 2 It is also recommended to monitor growth and development in infants and children on prolonged corticosteroid therapy 2. Alternate day therapy may be considered for patients requiring long-term pharmacologic corticoid therapy to minimize undesirable effects, including pituitary-adrenal suppression, the Cushingoid state, corticoid withdrawal symptoms, and growth suppression in children 2.

From the Research

Long Term Steroid Use Labs

• The use of long-term corticosteroids can lead to various adverse effects, including osteoporosis, which is one of the most serious consequences of this therapy 3.
• Patients on long-term corticosteroids should be monitored for bone density, urinary calcium level, and plasma calcifediol level, as well as serum testosterone levels when hypogonadism is suspected 3.
• Parameters to be monitored in primary care for patients on long-term oral corticosteroids include weight, blood pressure, triglycerides, glucose, and urea and electrolytes 4.
• Adverse effects of long-term oral corticosteroids can be prevalent, and monitoring for these effects is often inadequate, but can be improved with the use of quality improvement methodology and staff protocols 4.
• Different steroid regimens, such as daily oral steroids versus weekly oral pulse steroids, can have varying effects on bone mineral density and suprarenal suppression, with weekly oral pulse steroids potentially being a more favorable option 5, 6.
• Glucocorticoid exposure is a common cause of drug-induced osteoporosis, and significant risk factors for fracture development include age, prolonged glucocorticoid exposure, and low calcium intake 7.
• The risk of fracture decreases after cessation of glucocorticoid therapy, and patients at high risk for osteoporosis should have diagnostic testing, pre-medication management, and limitation of glucocorticoid therapy with a wait period between exposures 7.