Systemic steroids are also called corticosteroids, glucocorticoids or cortisones. They are synthetic derivatives of the natural steroid, cortisol, which is produced by the adrenal glands. They are called systemic if the steroids are taken by mouth or given by intramuscular injection. Topical (cortico)steroids are applied directly to the skin. Inhaled steroids are breathed in.
Systemic steroids include prednisone, prednisolone, methylprednisolone, beclamethasone, betamethasone, dexamethasone, fludrocortisone, hydrocortisone and triamcinolone.
Systemic steroids work in the same way as natural cortisol, and are prescribed for a large number of serious diseases. Skin conditions treated with steroids include blistering diseases such as pemphigus and pemphigoid, and severe forms of dermatitis.
What is the role of natural corticosteroids?
Natural cortisol has important effects in the body, including regulation of:
- Protein, carbohydrate, lipid and nucleic acid metabolism
- Inflammation and immune response
- Distribution and excretion of water and solutes
- Secretion of adrenocorticotrophic hormone (ACTH) from the pituitary gland.
How do systemic steroids differ?
Systemic steroids differ in dose, mineralocorticoid potency, half-life (duration of action) and how effectively they suppress the hyphothalamic-pituitary-adrenal (HPA) axis (suppression leads to reduced production of natural cortisol).
|Daily dose causing HPA axis suppression (mg)||25–30||20–30||7.5||7.5||1–1.5|
* Comparison of systemic corticosteroids – Vancouver Coastal Health Formulary tool. Accessed 12 July 2014.
What doses of systemic steroids are used?
Systemic steroids vary in strength. The beneficial effects as well as the side effects are proportional to the dose taken. Steroid dose is commonly characterised into:
- Low dose (e.g. <10mg/day of prednis(ol)one)
- Medium dose (e.g. 10-20 mg/day of prednis(ol)one)
- High dose (e.g. >20mg/day of prednis(ol)one, sometimes more than 100mg/day).
Treatment for less than one month is considered short term treatment. Treatment continuing for more than 3 months is regarded as long term, and results in the majority of undesirable side effects.
Corticosteroids for a few days or weeks are relatively safe, e.g. for acute dermatitis.
One must always carefully assess the severity of the underlying disorder, the gains that can be expected from corticosteroid therapy, and the risks. Excessive corticosteroid use is one of the causes of Cushing syndrome.
Side effects from a short course of systemic steroids
If systemic steroids have been prescribed for one month or less, side effects are rarely serious. However the following problems may arise, particularly when higher doses are taken:
- Sleep disturbance
- Increased appetite
- Weight gain
- Psychological effects, including increased or decreased energy
Rare but more worrisome side effects of a short course of corticosteroids include: mania, psychosis, delirium, depression with suicidal intent, heart failure, peptic ulceration, diabetes and aseptic necrosis of the hip. The risk increases with increasing dose.
Side effects from a longer course of systemic steroids
Nearly everyone on systemic steroids for more than a month suffers from some adverse effects, depending on daily dose and how long they have been on systemic steroids. These may include any of the following problems, which are not listed in any particular order of importance.
The skin is prone to the following adverse effects from prolonged courses or high doses of systemic steroids. These may include:
- Increased risk of skin infections such as bacterial infections (e.g. cellulitis) and fungal infections (e.g. tinea, candida)
- Skin thinning resulting in easy bruising (purpura), skin tearing after minor injury and slow healing; these effects are most prominent on sun exposed areas particularly the backs of the hands and the forearms.
- Stretch marks (striae), particularly under the arms and in the groin.
- Steroid acne: clusters of small spots on face, chest and upper back.
- Excessive hair (hypertrichosis) and hair loss (alopecia)
- Subcutaneous lipoatrophy (loss of fat under the skin surface) from injected steroid that does not go deep enough into the muscle.
Effects on body fat
- Redistribution of body fat results in moon face, buffalo hump and truncal obesity.
- Weight gain occurs in most patients on long-term steroids due to increased apetite and increased food intake.
Effects on the eye
- Glaucoma (increased intraocular pressure) can be due to corticosteroid eye drops as well as systemic steroids; often there is a family history of the disease.
- Posterior subcapsular cataracts in both eyes develop slowly; children are more susceptible than adults.
- Swelling of eyelids and eye muscles resulting in bulging eyes (exophthalmos) is a rare side effect.
- Central serous chorioretinopathy describes swelling within the eye resulting in separation of the choroid from the retina.
Atherosclerosis (hardening of the arteries) in patients on long-term steroids may lead to:
- Ischaemic heart disease: angina, heart attack (myocardial infarction), heart failure and atrial arrhythmias
- Stroke (cerebrovascular accident, CVA) and transient ischaemic attack (TIA)
- Increased all-cause mortality.
The effects of systemic steroids on atherosclerotic vascular disease may be due to complex metabolic changes, including:
- Reduction in release of ACTH (adrenocorticotropic hormone) leading to elevated VLDL (very low density lipoprotein), LDL (low density lipoprotein) cholesterol and triglycerides, and lower HDL (high density lipoprotein) cholesterol
- Peripheral insulin resistance and hyperinsulinaemia
- Gastritis and peptic ulceration may be caused by corticosteroids.
- Those also taking anti-inflammatory medications are at significantly increased risk of bleeding and should take acid-lowering medication to prevent this (e.g., a protein pump inhibitor such as omeprazole).
- Systemic steroids may mask symptoms, so that patients sometimes first learn of gastrointestinal disease when observing bleeding or when they become very ill from a perforation of the gut.
- There is an increased risk of fatty liver (hepatic steatosis) on long-term steroids.
- Sodium and fluid retention cause leg swelling and weight increase, usually in those with underlying heart or kidney disease.
- Increased blood pressure is common, especially with higher doses of steroid (more than 10mg of prednis(ol)one daily).
- Potassium loss may occur, causing general weakness.
Effects of continuous use of corticosteroids include:
- Irregular menstruation
- Lowered fertility in men and women
- Possible increased risk of cleft palate in offspring of women taking steroids in pregnancy
- Osteoporosis (thinning of the bones) due to corticosteroids is common, particularly in smokers, postmenopausal women, the elderly, those who are underweight or immobile, and patients with diabetes or lung problems. Osteoporosis may result in fractures of the spine, ribs or hip joint with minimal trauma. These occur after the first year in 10-20% of patients treated with more than 7.5mg prednis(ol)one daily. It is estimated that up to 50% of patients on long term oral corticosteroids will develop bone fractures.
- Osteonecrosis (destruction of bones such as the hip) is an uncommon but serious risk of high doses of steroids.
- Muscle weakness (myopathy) often affects shoulders and thighs.
- Vertebral fractures are more common in patients on steroids, even in those with normal bone density.
- Steroids prescribed to children reduce growth, which may not catch up when the steroids are discontinued after a prolonged course.
- Psychological effects include mood changes, increased energy, excitement and euphoria.
- Psychiatric symptoms are less common but include hypomania, psychosis, delirium, memory loss and depression, which may require assessment and treatment.
- Insomnia and sleep distrurbance is more likely with split doses and tends to be less severe if a single daily dose taken in the morning.
- Shakiness and tremor is more likely on higher doses.
- Headaches are common but serious raised intracranial pressure is rare.
- During and after steroid treatment, the adrenal gland produces less of its own cortisol, resulting from hypopituitary-pituitary-adrenal (HPA) axis suppression.
- Steroids may result in higher blood sugar (glucose) levels in patients with diabetes mellitus.
- Transient or persistent diabetes can affect previously nondiabetic patients, especially with higher daily doses of steroids. This needs treatment.
Glucocorticoids result in inhibition of innate and acquired immunity and affect T cells, B cells, phagocytes and cytokines. This makes them effective in controlling a wide range of inflammatory diseases but also leads to adverse events.
- Increased susceptibility to internal infections, especially when high doses are prescribed (e.g. tuberculosis).
- Raised white cell count, especially due to an increase in circulating neutrophils
- Reduced efficacy and increased risk of vaccines
Live vaccines such as polio or MMR (measles, mumps, rubella) should not be given to patients on higher doses of steroid (>20mg prednis(ol)one daily). It is safe and advisable to have other routine immunisations such as annual influenza vaccination.
Effects of reducing steroid dose
Side effects from reducing the dose include:
- Muscle and joint aches
The lack of steroid response to stress such as infection or trauma could result in severe illness for up to twelve months after the steroids are stopped.
Monitoring during steroid treatment
If you have been prescribed systemic steroids, make sure you understand how to take the medicine safely. Regular monitoring during treatment may include:
- Blood pressure
- Body weight
- Blood sugar
Discuss any side effects you may experience with your doctor.
Prevention of osteoporosis
Specific measures to reduce the chance of steroid-induced osteoporosis should be considered for patients that have taken or are expected to take 7.5 mg or more of prednisone or prednisolone each day for a period of three months or longer.
A DEXA bone scan measures bone density. Bone density gives an indication of the risk of fracture due to bone loss. Arrange to have a scan as you start systemic steroids, and it should be repeated every year or as recommended by your physician.
Preventative treatment includes the following medications:
- Adequate dietary intake (e.g. 3-4 dairy serves each day) or calcium tablets up to a daily intake of 1200mg calcium per day
- Vitamin D in various forms including monthly colecalciferol 50,000 units (1.25 mg)
- Oestrogen i.e. hormone replacement tablets in females that have had early menopause
- Bisphosphonates (alendronate, etidronate, zolidronic acid); these are prescribed for patients at higher risk of fracture.
Treatment is most effective when started at the same time as the steroids, as most bone loss occurs within the first few months. This is most important for people taking more than 7.5mg of prednis(ol)one (or the equivalent dose of another oral corticosteroid) for three months or longer.
If you smoke, stop. Consume minimal alcohol. Take regular weight bearing exercise e.g. walking for 30 to 60 minutes each day.
Reducing the dose of systemic steroids
Do not suddenly stop systemic steroids; your doctor will explain how to gradually come off them (particularly important if you have been on them for more than six weeks).
- No tapering is necessary if the course of steroids has been for less than one week.
- After taking a dose of 30 mg or more per day for 3-4 weeks, reduce the dose by 10 mg or less per day, taking days to weeks to stop altogether.
- A much slower reduction in dose may be required if the medication has been taken for several months or longer.
- Alternate day dosing may reduce side effects.
On DermNet NZ:
- FRAX® WHO Fracture Risk Assessment Tool
- Consumer medicine information and data sheets – Medsafe
- Drugs, Herbs and Supplements – MedlinePlus
- Medsafe on osteoporosis due to systemic steroids
- Oral treatment with corticosteroids – British Association of Dermatologists
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New Zealand approved datasheets are the official source of information for these prescription medicines, including approved uses and risk information. Check the individual New Zealand datasheet on the Medsafe website.