Steroid-Induced Complications (Corticosteroid Side Effects)

How corticosteroids work

Corticosteroids mimic cortisol, a hormone made by the adrenal glands. In higher doses than the body makes naturally, they reduce inflammation and calm the immune system. This makes them valuable for asthma, COPD flares, rheumatoid arthritis, lupus, inflammatory bowel disease, allergies, skin diseases and many other conditions. The same effects, spread across the whole body, cause side effects.

Risk depends on dose, duration and route. Inhaled, topical and joint injections cause fewer whole-body effects than tablets or IV steroids, though high-dose inhaled or widespread topical use can still have effects.

Short-term side effects

Even short courses can cause:

• Raised blood sugar, especially in people with diabetes or prediabetes
• Insomnia
• Mood changes: irritability, anxiety, euphoria, and occasionally severe psychiatric symptoms
• Increased appetite
• Indigestion
• Fluid retention and raised blood pressure
• Facial flushing

Long-term side effects

Adrenal suppression and steroid withdrawal

Taking steroids for more than about 3 weeks, or repeated courses, tells the adrenal glands to stop making cortisol. If steroids are stopped suddenly, or the body faces extra stress such as illness, injury or surgery, it may not have enough cortisol, leading to adrenal crisis: severe weakness, vomiting, low blood pressure and collapse.

To stay safe:

• Never stop long-term steroids suddenly. Your doctor will taper the dose.
• Follow sick day rules your doctor gives you, which often involve temporarily increasing the dose during illness.
• Carry a steroid emergency card or medical alert ID.
• Tell anyone treating you, including surgeons and dentists, that you take steroids.

Some people also experience steroid withdrawal symptoms such as fatigue, aches and low mood during tapering, even with normal adrenal function.

Who is at higher risk

• High doses or long-term use
• Older adults
• People with diabetes, osteoporosis, glaucoma, high blood pressure or a history of stomach ulcers
• Children (growth effects)
• People taking other immune-suppressing medicines

Monitoring

• Blood pressure and weight
• Blood sugar, especially at the start of treatment
• Bone density scan (DEXA) and fracture risk assessment for people on steroids for 3 months or more
• Eye checks for cataracts and eye pressure
• Growth in children
• Screening for infections such as tuberculosis and hepatitis B before high-dose or long-term treatment, in some cases

Reducing the risks

• Lowest effective dose, shortest time.
• Steroid-sparing medicines such as methotrexate, azathioprine or biologic drugs for long-term conditions.
• Local treatments (inhalers, creams, joint injections) where possible.
• Bone protection: calcium and vitamin D, weight-bearing exercise and, for many people on long-term steroids, bone-strengthening medicines such as bisphosphonates.
• Stomach protection if you also take NSAIDs or have a history of ulcers.
• Infection prevention: recommended vaccines (flu, pneumococcal, shingles vaccine where appropriate) and, at high doses, preventive antibiotics for pneumocystis.
• Take morning doses to reduce insomnia.
• Healthy diet and activity to limit weight gain and blood sugar rises.

Frequently asked questions

What are the most common side effects of prednisone?

Common short-term effects include increased appetite, trouble sleeping, mood changes, raised blood sugar and indigestion. With long-term use, weight gain, a rounded face, thin skin, easy bruising, bone thinning, diabetes, cataracts and a higher risk of infections become more common.

Why can't you stop steroids suddenly?

After several weeks of steroid treatment, your adrenal glands make less of their own cortisol. Stopping suddenly can leave you without enough cortisol, causing weakness, vomiting, low blood pressure and possibly a life-threatening adrenal crisis. Doses are tapered gradually under medical guidance.

Do short courses of steroids cause side effects?

Yes, but they are usually temporary. A course of a few days to two weeks can raise blood sugar, disrupt sleep, increase appetite and affect mood. Repeated short courses add up over time and can contribute to longer-term effects such as bone loss and diabetes.

How can I protect my bones while taking steroids?

Get enough calcium and vitamin D, do weight-bearing exercise, avoid smoking and limit alcohol. If you take steroids for 3 months or longer, ask about a bone density scan and fracture risk assessment. Many people benefit from bone-protecting medicines such as bisphosphonates.