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Systemic steroids

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:

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).

Comparison of systemic steroids*
Drug Cortisone Hydrocortisone Prednisone Methylprednisolone Dexamethasone
Equivalent dose 25 20 5 4 0.75
Mineralocorticoid potency 2+ 2+ 1+ 0-0.5+ 0
Biological half-life 8–12 8–12 24–36 24–36 36–54
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:

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:

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.

Skin problems

The skin is prone to the following adverse effects from prolonged courses or high doses of systemic steroids. These may include:

Moon face
Moon face
Easy bruising
Skin thinning
Skin thinning
Fragile skin
Fragile skin
Stretch marks
Stretch marks
Adverse effects of systemic steroids

Effects on body fat

Effects on the eye

Vascular disease

Atherosclerosis (hardening of the arteries) in patients on long-term steroids may lead to:

The effects of systemic steroids on atherosclerotic vascular disease may be due to complex metabolic changes, including:

Gastrointestinal tract

Fluid balance

Reproductive system

Effects of continuous use of corticosteroids include:

Musculoskeletal system

Nervous system

Metabolic effects

Immune response

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.

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:

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:

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:

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).

Related information

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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.

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If you have any concerns with your skin or its treatment, see a dermatologist for advice.