By Theodore R. Fields, MD, FACP
How to think about the suggestions below? Any suggestion here which is not clear or which you think may not apply to you should be discussed with your physician. Note also 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.
Note on which “steroids” are we talking about: 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.
Understanding corticosteroid side effects
With long-term use, corticosteroids can result in any of the following side effects. However, taking care of yourself as discussed below may reduce the risks.
Increased doses needed for physical stress
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.
- Discuss this possibility with the surgeon or dentist, etc. who is taking care of you at the time. Your physician or surgeon may not feel you need to take the extra steroid at the time of surgery, but if they know you have been on corticosteroids they can watch you more carefully after surgery.
Steroid withdrawal syndrome
When anti-inflammatory steroids have been taken for some time and then are rapidly withdrawn, our adrenal gland (which makes our body’s steroid hormones) can be sluggish in making our own steroid hormone.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 in 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.
- If you get symptoms like these when you taper your steroids, discuss them with the doctor. Your physician will work with you to continually try to taper your steroid dose, at a safe rate of decrease, depending on how you are doing. On each visit, discuss with the physician whether it is possible to decrease your steroid dose.
- Note that even if you are having a steroid side effect, however, steroids still must be tapered slowly.
- When used for less than two weeks, more rapid tapering of steroids is generally possible.
Long-term steroids can suppress the protective role of your immune system and increase your risk of infection.
- Since steroids can decrease your immunity to infection, you should have a yearly flu shot as long as you are on steroids. If you are on steroids for a prolonged period of time, you should also discuss with your doctor the possibility of getting “Pneumovax,” a vaccination against a certain type of pneumonia as well as “Prevnar 13,” another pneumonia vaccine. Shingles vaccination (Shingrix®) may also be considered. Your physician will take your age and risk factors into account when deciding which vaccinations you need.
- Signs of possible infection, such as high fever, productive cough, pain while passing urine, or large “boils” on the skin should have prompt medical attention. If you have a history of tuberculosis, exposure to tuberculosis, or a positive skin test for tuberculosis, report this to your doctor.
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.
- Report to your physician any severe, persisting abdominal pain or black, tarry stools.
- Take the steroid mediation after a full meal or with antacids, as this may help reduce irritation of the stomach. Steroids can increase your appetite.
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 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.
- Most people taking corticosteroids will need to take a calcium supplement unless they can get enough calcium from their diet (if you can get it from your diet, that’s the best option). See this reference from the National Institutes of Health about how much calcium you need for your sex and age, and how to get as much as possible from diet.
- The minimal daily requirement of vitamin D is 800 international units (UI) daily, and most people on corticosteroids should take this amount. Your physician may check your vitamin D level and see if you actually need a higher dose.
- Smoking and alcohol increase the risk of osteoporosis, so limiting these is helpful.
- Weight-bearing exercise (walking, running, dancing, etc) is helpful in stabilizing bone mass.
- People on corticosteroids who have low bone density may be put on medications such as alendronate (Fosamax®) or Prolia®, and there are a number of others.
- Assess risk of falls. Make a thorough examination of your home and correct situations that might result in a fall, such as eliminating scatter rugs and any obstacles between bedroom and bathroom, and installing night lights.
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.
- Watch your calories and exercise regularly to try to prevent excessive weight gain. But don’t let weight gain damage your self-esteem. Know that the weight will be easier to take off in the six months to a year after you discontinue steroids.
Steroids may impair your ability to fall asleep, especially when they are taken in the evening.
- If possible, the physician will try to have you take your entire daily dose in the morning. This may help you sleep better at night (evening doses sometimes make it difficult to fall asleep).
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.
- Simply being aware that steroids can have an effect on your mood can sometimes make it less of a problem. But, at times, this side will require that the steroid dosage be decreased. If maintaining the same steroid dosage is absolutely necessary, sometimes another medication can be added to help with the mood problem.
- Make sure your family and friends know about this possible side effect so they will know what’s going on if you respond to them in unexpected ways. Ideally, tell your family and friends about this possible side effect as you start the medication, so that they can help you detect any changes in your behavior.
Fluid retention and elevated blood pressure
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.
- Watch for swelling of your ankles, and report this to your doctor. Occasional patients benefit from diuretics (water pills). Low sodium diet helps reduce fluid accumulation and may help control blood pressure.
- Have your blood pressure monitored regularly while you are on steroids, especially if you have a history of high blood pressure. Steroids can raise blood pressure in some patients.
Elevated blood sugar
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.
- Your blood sugar should be followed while you are on steroids, especially if you are a diabetic, since corticosteroids can raise blood sugar.
Steroids can sometimes cause cataracts or glaucoma (increased pressure in the eye).
- If you have a history of glaucoma or cataract follow up closely with the ophthalmologist while on steroids. If you develop any visual problems while on steroids, you will need to see the ophthalmologist. Temporarily blurred vision when you start corticosteroids is often not a serious problem, but ophthalmology evaluation should always be arranged if you experience other, new visual symptoms while taking steroids.
Atherosclerosis (hardening of the arteries)
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.
- Low cholesterol diet may help. If you develop signs suggesting heart problem, such as chest pain, get medical attention quickly. Work with your physician to address any heart risks that can be modified, such as exercise, weight and cholesterol level.
- Steroids, particularly at higher doses for long periods of time, can sometimes lead to damage to bones, called aseptic necrosis (also known as osteonecrosis or avascular necrosis). This can happen in a number of joints, but the hip is the most common.
- Hip pain, especially if you have no known hip arthritis, could be an early sign of this damage. Report this to your doctor.
Attending Physician, Hospital for Special Surgery
Professor of Clinical Medicine, Weill Cornell Medical College