SN3 SHORT NOTE 5M ★ High-yield

Describe the complications of long-term corticosteroid therapy and the principles of withdrawal.

Pharmacology · 2nd Professional — Para-Clinical

WHY Withdrawal Is Dangerous

Exogenous corticosteroid provides negative feedback at the hypothalamus and pituitary → CRH and ACTH secretion fall → Without ACTH stimulation the adrenal cortex atrophies → Suppression occurs after roughly 2–3 weeks of supraphysiological dosing → If the steroid is stopped abruptly, there is neither exogenous nor endogenous cortisol → acute adrenal insufficiency — weakness, vomiting, abdominal pain, hypotension, hypoglycaemia, hyponatraemia, hyperkalaemia, shock → Recovery of the axis takes months to a year after prolonged therapy

CLINICAL PEARL

The adrenal gland cannot distinguish a tapering dose from a falling illness. What it responds to is the total glucocorticoid signal, so recovery depends on that signal falling slowly enough for ACTH to rise and the cortex to regrow. A taper is not a courtesy to the patient’s symptoms; it is the time the gland physically needs. Which is also why a patient on a slow taper still cannot mount a stress response and still needs extra steroid for illness or surgery.

Complications of Long-term Therapy

System	Complication	Prevention or monitoring
Bone	Osteoporosis — loss is fastest in the first 6 months; vertebral and rib fractures; avascular necrosis of the femoral head	Calcium and vitamin D from the start; a bisphosphonate if treatment is expected to exceed 3 months; bone density measurement
Metabolic	Steroid-induced diabetes, hypertension, dyslipidaemia, hypokalaemia	Monitor glucose, blood pressure and potassium
Infection	Increased susceptibility with masked signs; reactivation of tuberculosis and Strongyloides; candidiasis; herpes zoster	Screen for tuberculosis and Strongyloides before prolonged therapy; vaccinate (not live vaccines during treatment); high index of suspicion
Eye	Posterior subcapsular cataract, glaucoma	Periodic ophthalmic review
Gastrointestinal	Peptic ulceration, greatly increased with an NSAID	Proton pump inhibitor if an NSAID is unavoidable
Muscle and skin	Proximal myopathy, thin skin, striae, bruising, poor wound healing	Dose reduction
CNS	Insomnia, euphoria, depression, psychosis	Morning dosing; dose reduction
Children	Growth suppression	Plot height at every visit; alternate-day dosing

Strategies to Minimise Harm

Lowest effective dose for the shortest time, with a defined review date
Single morning dose — mimics the diurnal peak and causes less axis suppression than the same dose divided
Alternate-day regimens where the disease permits — they allow partial recovery of the axis on the off day, and reduce growth suppression in children
Local routes wherever possible — inhaled, topical, intra-articular, intralesional, rectal; systemic absorption is far lower
Steroid-sparing agents — methotrexate, azathioprine, mycophenolate or a biological, introduced specifically so that the steroid can be withdrawn
Bone, gastric and glycaemic protection from the outset rather than after a complication appears

Rules for Withdrawal and Stress Cover

Taper if treatment has exceeded about 3 weeks, or if the dose was high, or if there have been repeated courses
Reduce rapidly to a physiological dose (about 5 to 7.5 mg prednisolone), then slowly thereafter, watching for both adrenal insufficiency and relapse of the underlying disease
"sick day rules" — double the dose during fever or intercurrent illness; give parenteral hydrocortisone if vomiting; and give stress doses for surgery, trauma or labour
A steroid card or alert bracelet for every long-term patient
Steroid withdrawal syndrome — lethargy, arthralgia, myalgia, fever and mood change even with a normal cortisol; managed by slowing the taper

Applied Aspects

Never stop steroids abruptly in a patient admitted for another reason, and ensure a parenteral route is arranged if they are nil by mouth
Ask about steroid use in any unexplained hypotension, including over-the-counter and traditional preparations
Unregulated steroid use is a real problem in India — steroids are present in many topical creams sold over the counter and in some traditional remedies, and patients present with iatrogenic Cushing syndrome or adrenal crisis having never knowingly taken a steroid
Ask specifically about skin creams and joint injections, which patients do not consider medicines
Screen for tuberculosis before prolonged steroids in India; reactivation is common and may be disseminated
Warn about the psychiatric effects at the start, particularly with high doses; families find them far less alarming when forewarned

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