Corticosteroids exert anti-inflammatory effects throughout the body and are often prescribed to treat chronic inflammatory conditions like lupus, rheumatoid arthritis, or sarcoidosis. They may also be appropriate to treat episodes of inflammation associated with crystalline arthritic diseases such as gout or pseudogout.
But prolonged use can cause numerous side effects. Corticosteroids can provide major benefits in many diseases, and may even be life-saving, but prolonged use can cause numerous side effects. This article discusses ways to reduce the risk and severity of side effects if you need to take corticosteroids.
Any suggestion here which is not clear or which you think may not apply to you should be discussed with your doctor. Please also note that the side effects of steroids very much depend on the dose and how long they are taken. If your dose is low, your risk of serious side effect is quite small, especially if precautions, as discussed below, are taken. Reading about these side effects may make you uncomfortable about taking steroids. You should be well aware of the risks before starting these medications. However, please be reassured that many people take steroids with minor or no side effects. Please also remember that steroids are often extremely effective and can be life-saving. If any of the suggestions here is unclear, or seems irrelevant to you, please discuss it with your physician.
The term “steroids” here refers to anti-inflammatory steroids (corticosteroids) such as prednisone and methylprednisolone (Medrol®) and dexamethasone (Decadron®). The information below does not refer to muscle-building or “androgenic” steroids (such as testosterone), which share some chemical similarities but function quite differently than anti-inflammatory steroids. Also, in general, this article refers to side effects related to prolonged use of oral, inhaled or infused corticosteroids, rather than to occasional, local steroid injections. Corticosteroid side effects are very much related to dose and duration. For this reason, when corticosteroids are injected locally to treat joint pain, nerve pain or other musculoskeletal pain, and these injections are spaced out in time, it is quite unusual to see the side effects that can come with the chronic use of these medications.
With long-term use, corticosteroids can result in many side effects, including a need for increased doses to manage physical stress, steroid withdrawal syndrome, insomnia, mood changes, elevated blood pressure or blood sugar levels, infections, gastrointestinal symptoms, increased appetite and subsequent weight gain, osteoporosis, cataracts or glaucoma in the eyes, hardening of the arteries or avascular necrosis. However, there are ways to reduce these risks by taking care of yourself.
Steroid use for over two weeks can decrease the ability of your body to respond to physical stress. A higher dose of steroid may be needed at times of major stress, such as surgery or very extensive dental work or serious infection. This could be needed for as long as a year after you have stopped steroids.
When anti-inflammatory steroids have been taken for some time and then are rapidly withdrawn, our adrenal gland (which makes our body’s steroid hormones) can be sluggish in making our own steroid hormone. Taking anti-inflammatory steroids can lead to inhibition of the complex pathway that leads to our body’s production of anti-inflammatory steroid hormone (cortisol). Taking these anti-inflammatory steroids can suppress the hypothalamus, as well as the pituitary gland, which are all involved the process of stimulating the adrenal gland to make cortisol. For example, the pituitary gland production of ACTH (which stimulate the adrenal to make cortisol) can be inhibited. The adrenal gland itself can also show some suppression of its ability to make cortisol.
Rapid withdrawal of steroids may cause a syndrome that could include fatigue, joint pain, muscle stiffness, muscle tenderness, or fever. These symptoms could be hard to separate from those of your underlying disease. Even with slower withdrawal of steroids, some of these symptoms are possible, but usually in milder forms.
At times, rapid withdrawal of steroids can lead to a more severe syndrome of adrenal insufficiency. This can cause symptoms and health problems such as drops in blood pressure, as well as chemical changes in the blood such as high potassium or low sodium. Sometimes this can be set off by injuries or a surgical procedure. Because of this, make sure your doctors always know if you have been treated with steroids in the past, especially in the past year, so they can be on the alert for the development of adrenal insufficiency at times such as a surgical procedure.
Long-term steroids can suppress the protective role of your immune system and increase your risk of infection.
Steroids may increase your risk of developing ulcers or gastrointestinal bleeding, especially if you take these medications along with non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen or aspirin. If at all possible, don’t combine steroids with NSAIDs. If you are on low-dose aspirin for heart protection, your physician may want you to continue this when you take the prednisone, but might consider adding a medication for stomach protection during the course of steroids.
Steroid therapy can cause thinning of the bones (osteopenia and osteoporosis), and increase the risk of bone fractures. At the beginning or before your steroid therapy, many patients will be asked to have a bone density test, especially if the steroid dose is high. If density is low, the bone density study It will be repeated in the future to assess the effectiveness of measures you will be using to prevent bone loss. Preventative strategies are important: a person can lose 10% to 20% bone mass within the first six months of corticosteroid therapy.
Steroids affect your metabolism and how your body deposits fat. This can increase your appetite, leading to weight gain, and in particular lead to extra deposits of fat in your abdomen.
Steroids may impair your ability to fall asleep, especially when they are taken in the evening.
Steroids, especially in doses over 30 milligrams per day, can affect your mood. Some people can feel depressed, some extremely “up” without any apparent reason. Just being aware that steroids can do this sometimes makes it less of a problem. Sometimes, this side effect requires that the steroid dosage be decreased. When the steroids are absolutely necessary, sometimes another medication can be added to help with the mood problem. Make sure your family knows about this possible side effect.
Because cortisone is involved in regulating the body's balance of water, sodium, and other electrolytes, using these drugs can promote fluid retention and sometimes cause or worsen high blood pressure.
Since cortisone is involved in maintaining normal levels of glucose (sugar) in the blood, long-term use may lead to elevated blood sugar or even diabetes.
Steroids can sometimes cause cataracts or glaucoma (increased pressure in the eye).
It is possible that steroids may increase the rate of "hardening of the arteries," which could increase the risk of heart disease. This risk is probably much more significant if steroids are taken for more than a year, and if taken in high dose.
Theodore R. Fields, MD, FACP
Attending Physician, Hospital for Special Surgery
Professor of Clinical Medicine, Weill Cornell Medical College