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Systemic corticosteroid use

September 27, 2016 by ASK DR BLOOM

Corticosteroids are used for their anti-inflammatory and immunomodulatory properties to treat a wide spectrum of disease. Indications for use of steroids in otolaryngology include rhinosinusitis, rhinitis, facial nerve paralysis, hearing loss, Menieres’s disease, croup, nasal polyposis, and temporal arteritis.

Complications include disruption of the hypothalamic-pituitary-adrenal axis, hyperglycemia and glucose intolerance, and numerous gastrointestinal and psychiatric effects. Consequences of long-term steroid use include osteoporosis, avascular necosis of the hip, cushingoid body changes, cataract formation, dermatologic manifestations and atherosclerosis. The most dangerous complication is the risk of infection associated with the acquired immunodeficiency of chronic steroid use.

Avascular necrosis of the hip is a devastating complication that occurs in approximately 1 in 300 patients. It has been associated with doses as low as 290 mg of prednisone and durations as low as 6 days.

Severe psyciatric reactions occur 1.3%, 4.6% and 18.4%, respectively with doses lower than prednisone 40 mg daily, prednisone 40-80 mg daily and greater than prednisone 80 mg daily. The severe reactions include mania, depression (suicidal ideations), a mixed state and aggressiveness. The mild effects occur in a range of 13-62% and include agitation, anxiety, distractibility, fear, hypomania, indifference, insomnia, irritability, lethargy, mood lability, pressured speech, restlessness, and tearfulness.

Redistribution of adipose tissue (cushingoid changes) are a common effect of prolonged steroid use. They include truncal obesity, facial adipose tissue (moon facies), and dorsocervical adipose tissue (buffalo hump). These changes occur in 15% of patients in less than 3 months with doses of 10-30 mg daily of prednisone. Higher doses and longer duration increase the frequency.

In addition to the adipose tissue changes, steroids cause cutaneous complications including skin atrophy, striae, ecchymoses, and changes in the mechanical properties of the skin. These skin changes are more commonly found with topical application of steroids.

Corticosteroids inhibit the natural wound healing process in several ways ultimately causing delayed wound healing and decreased tensile strength. epdiermal growth factor, transforming growth factor factor beta, platelet-derived gwoth factor, tetrachlorodecaoxygen, vitamin A and insulinlike growth factor 1 may counter the impact of steroids on wound healing.

Systemic administration of steroids can lead to cataract formation, increased intraocular pressure (glaucoma), myopia, exophthalmos, papilledema, central serous chorioretinopathy and subconjunctival hemorrhages. Doses as low as 5 mg of prednisone for as little as 2 months can lead to cataract formation but most cases involve greater than 10 mg for over a year.

There is a perception that steroids can increase the risk of peptic ulcer disease. However, several large meta-anylsis have failed to show this association. Gastritis and pancreatitis are more common in patients taking steroids.

AskDrBloom.com

References:

Poetker DM and DD Reh. A comprehensive review of the adverse effects of systemic corticosteroids. Otolaryngol Clin N Am. 2010: 43:753-768.

Nash JJ etal. Medical malpractice and corticosteroid use. Otolaryngol Head Neck Surg. 2011; 144(1):10-15.

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