Corticosteroids: Precautions

The most significant risk associated with administration of glucocorticoids is suppression of natural corticosteroid secretion. When the hormones are administered, they suppress the secretion of ACTH, which in turn reduces the secretion of the natural hormones. The extent of suppression varies with dose, drug potency, duration of treatment, and individual patient response. While suppression is seen primarily with drugs administered systemically, it can also occur with topical drugs such as creams and ointments, or drugs administered by inhalation. Abrupt cessation of corticosteroids may result in acute adrenal crisis (Addisonian crisis) that is marked by dehydration with severe vomiting and diarrhea, hypotension, and loss of consciousness. Acute adrenal crisis is potentially fatal.

Chronic overdose of glucocorticoids leads to Cushingoid syndrome, which is clinically identical to Cushing's syndrome and differs only in that in Cushingoid, the excessive steroids are from drug therapy rather than excessive glandular secretion. Symptoms vary, but most people have upper body obesity, rounded face, increased fat around the neck, and thinning arms and legs. In its later stages, this condition leads to weakening of bones and muscles with rib and spinal column fractures.

The short term adverse effects of corticosteroids are generally mild, and include indigestion, increased appetite, insomnia, and nervousness. There are also a very large number of infrequent adverse reactions, the most significant of which is drug induced-paranoia. Delerium, depression, menstrual irregularity, and increased hair growth are also possible. Consult detailed reviews for further information.

Long-term use of topical glucocorticoids can result in thinning of the skin. Oral steroid inhalations may cause fungal overgrowth in the oral cavity. Patients must be instructed to rinse their mouths carefully after each dose. Corticosteroids are pregnancy category C. The drugs have caused congenital malformations in animal studies, including cleft palate. Breastfeeding should be avoided.

Because fludrocortisone has glucocorticoid activity as well as mineralocorticoid action, the same hazards and precautions apply to fludrocortisone as to the glucocorticoids. Overdose of fludrocortisone may also cause edema, hypertension, and congestive heart failure.

Corticotropin has all the same risks as the glucocorticoids. Prolonged use may cause reduced response to the stimulatory effects of corticotropin.

Use corticosteroids with caution in patients with the following conditions:

• osteoporosis or any other bone disease
• current or past tuberculosis
• glaucoma or cataracts
• infections of any type (virus, bacteria, fungus, amoeba)
• sores in the nose or recent nose surgery (if using nasal spray forms of corticosteroids)
• underactive or overactive thyroid
• liver disease
• stomach or intestine problems
• diabetes
• heart disease
• high blood pressure
• high cholesterol
• kidney disease or kidney stones
• myasthenia gravis
• systemic lupus erythematosus (SLE)
• emotional problems
• skin conditions that cause the skin to be thinner to bruise more easily

Corticosteroids have many drug interactions. Consult specific references.

— Samuel Uretsky, PharmD