Key Facts

Corticosteroids are among the most versatile and widely used drugs in medicine. Their potent anti-inflammatory effects make them invaluable, but their extensive side effect profile requires careful prescribing, monitoring, and patient education.

Pharmacology

• Bind cytoplasmic glucocorticoid receptor → translocate to nucleus → modulate gene transcription
• Anti-inflammatory: ↓ IL-1, IL-6, TNF-alpha, prostaglandins, leukotrienes; ↓ neutrophil migration; ↓ capillary permeability
• Immunosuppressive: ↓ T-cell proliferation, ↓ antibody production
• Metabolic: ↑ gluconeogenesis (→ hyperglycaemia), ↑ protein catabolism, ↑ lipolysis, Na/water retention

Potency Comparison

Pathophysiology of Side Effects

• Adrenal suppression: exogenous steroids suppress ACTH via negative feedback → adrenal cortex atrophies → cannot produce cortisol on withdrawal → adrenal crisis
• Osteoporosis: ↓ osteoblast activity, ↑ osteoclast activity, ↓ calcium absorption, ↓ sex hormones
• Hyperglycaemia: ↑ gluconeogenesis, ↑ insulin resistance → steroid-induced diabetes
• Immunosuppression: ↓ cell-mediated immunity → increased infection risk (TB reactivation, opportunistic infections)

Common Indications

• Asthma/COPD exacerbation: prednisolone 40 mg OD for 5 days (NICE NG80)
• Autoimmune diseases: SLE, PMR/GCA, autoimmune hepatitis, IBD
• Allergic reactions: anaphylaxis (adjunct), severe allergic rhinitis
• Cerebral oedema: dexamethasone 8–16 mg/day (brain tumours, meningitis)
• Adrenal insufficiency: hydrocortisone replacement 15–25 mg/day
• Organ transplant: immunosuppressive regimen
• COVID-19: dexamethasone 6 mg OD for 10 days (RECOVERY trial — 35% mortality reduction in ventilated patients)

Side Effects (Long-Term)

• Metabolic: weight gain, Cushingoid features, diabetes, hyperlipidaemia
• MSK: osteoporosis, fractures, avascular necrosis (hip), proximal myopathy
• GI: peptic ulceration (especially with NSAIDs), pancreatitis
• CVS: hypertension, fluid retention
• Neuro/psych: insomnia, mood disturbance, psychosis, depression
• Skin: thin skin, easy bruising, striae, poor wound healing, acne
• Eyes: cataracts, glaucoma
• Infection: increased susceptibility; may mask infection signs; TB reactivation
• Endocrine: adrenal suppression, growth retardation in children

Red Flags

• Adrenal crisis: collapse, hypotension, hypoglycaemia, confusion after abrupt steroid withdrawal or during intercurrent illness → IV hydrocortisone 100 mg stat
• Sepsis in steroid-treated patient: may not mount typical inflammatory response; maintain high index of suspicion
• Steroid-induced psychosis: agitation, hallucinations, mania — usually with high doses; reduce dose
• New vertebral fracture: back pain in patient on long-term steroids → DEXA, X-ray

Before Starting Long-Term Steroids

• Baseline: weight, BP, blood glucose/HbA1c, bone profile, lipids
• DEXA scan: if expected to take steroids ≥3 months
• Screening: TB (IGRA/CXR if risk factors), hepatitis B, Strongyloides (if tropical exposure)
• Varicella immunity: check if non-immune — varicella can be fatal in immunosuppressed

Monitoring

• Blood glucose: regularly, especially first 2–4 weeks (steroid-induced diabetes common)
• BP: each clinic visit
• Weight: monitor for Cushingoid changes
• DEXA: if on steroids ≥3 months — repeat at 2 years
• Eye review: annual if on long-term steroids (cataracts, glaucoma)
• Bone profile, vitamin D: periodically

Special Tests

• Short synacthen test: if adrenal insufficiency suspected after long-term steroid use (test before restarting if stopped)
• 9 am cortisol: screening for adrenal suppression during tapering

Prescribing Principles

• Lowest effective dose for shortest duration
• Morning dosing: mimics physiological cortisol rhythm; reduces insomnia
• Steroid card/emergency card: all patients on steroids ≥3 weeks should carry
• Sick day rules: double dose during illness/surgery/trauma

Bone Protection

• If expected steroid use ≥3 months: start bone protection
• Alendronate 70 mg weekly + calcium 1000 mg/day + vitamin D 800 IU/day
• Alternative: risedronate, denosumab (if bisphosphonate contraindicated)

Tapering

• Short courses (≤3 weeks): can stop abruptly
• Courses >3 weeks or repeated courses: taper gradually to avoid adrenal crisis
• Typical taper: reduce prednisolone by 5 mg every 1–2 weeks until 5 mg, then by 1 mg every 2–4 weeks
• Monitor for adrenal insufficiency symptoms during tapering

Adrenal Crisis Management

• IV hydrocortisone 100 mg stat then 50 mg QDS until stable
• IV 0.9% saline (fluid resuscitation)
• Treat precipitant (infection, surgery)

Referral Criteria

• Endocrinology: adrenal insufficiency, steroid weaning failure, Cushing's
• Rheumatology: steroid-sparing agent guidance in autoimmune disease
• Ophthalmology: cataracts, raised IOP

• Short courses: minimal long-term effects
• Prednisolone >7.5 mg/day for >3 months: significant osteoporosis, diabetes, and adrenal suppression risk
• RECOVERY trial: dexamethasone 6 mg for COVID-19 — 35% mortality reduction in ventilated patients
• GCA: untreated → permanent visual loss; prednisolone 40–60 mg prevents this
• Adrenal crisis: potentially fatal if not recognised and treated promptly
• Steroid-induced osteoporosis: preventable with bone protection — alendronate reduces fracture risk by ~40–50%

Steroid Equivalence Table

When to Taper vs Stop Abruptly