Corticosteroids (such as prednisone or dexamethasone) are synthetic analogs of the naturally occurring hormone cortisol. They play a crucial role in the treatment of autoimmune, allergic, and inflammatory conditions. However, abruptly stopping these drugs without gradual tapering can have serious effects.
The role of cortisol in our body:
Cortisol is a natural glucocorticoid hormone. The adrenal gland produces cortisol by cholesterol metabolism. Similar pathways produce other steroid hormones, such as aldosterone, progesterone, estrogen, and testosterone, which are essential for various body functions.
The production of cortisol in the body is regulated by the hypothalamic-pituitary-adrenal (HPA) axis in the brain. Physical and psychological stressors, such as infections, trauma, or diseases, can cause a dramatic increase in cortisol production, sometimes up to ten times more than the usual levels. Cortisol is produced by the adrenal gland and affects almost every organ and metabolic process, including the metabolism of carbohydrates, proteins, fats, and minerals like calcium. Corticosteroids have a wide impact on various body systems, including the cardiovascular, central nervous, and endocrine systems.
Why Tapering Is Crucial?
Corticosteroids suppress the HPA axis and functions of the adrenal gland. Longer use reduces the body's capability to produce cortisol due to adrenal suppression.
Lack of cortisol in our body results in potentially life-threatening side effects with abrupt stopping.
Short-term side effects:
Corticosteroids with short-term use can have side effects, which usually resolve once the medication is stopped. These side effects include:
High blood sugar levels
High blood pressure
Mood and sleep disturbances
Increased risk of sepsis
Bone fractures
Venous thromboembolism (VTE)
In 2017, a study by Waljee et al. utilized national data sets of private insurance claims of steroid prescriptions for 327,452 patients aged between 18 and 64 years. This study excluded patient who uses steroids for chronic illnesses such as cancer, asthma, COPD, and autoimmune diseases. According to this study, short-term use of corticosteroids is associated with five times increased risk of sepsis, three times increased risk of venous thromboembolism(VTE), and almost twice the greater risk of fractures when used for five to thirty days.
Long-Term Side Effects:
The long-term use of corticosteroids can have severe side effects, including but not limited to:
1. Cushingoid Features: Steroids can exert Cushing syndrome, which is characterized by weight gain and unusual fat disposition, a.k.a "buffalo hump," or "moon, face" due to excess corticosteroids in the body. These side effects can be seen within a couple of months of administering high doses of corticosteroids.
2. Osteoporosis and Fractures: Low bone mineral density(BMD), also known as bone loss, can be experienced by the lowest dose of corticosteroid with long-term use..
3. Diabetes and Hyperglycemia: Corticosteroids, one of the drugs that can cause diabetes mellitus, can increase insulin resistance in patients with diabetes mellitus.
4. Myopathy: Corticosteroids can also cause muscle weakness and muscle loss due to decreased production and increased degradation of proteins. These effects are stopped a few weeks after stopping the corticosteroid treatment.
In conclusion, Steroid treatment should be stopped under medical supervision only. Corticosteroid tapering is crucial in allowing the body to adjust and regain its normal cortisol production. Side effects can be seen with both short-term and long-term use. A gradual reduction in corticosteroid dosing provides safer discontinuation and is essential to reduce the risk of adverse effects.
References:
1. You and your hormones. (n.d.). https://www.yourhormones.info/hormones/cortisol/
2. Williams, D. M. (2018). Clinical pharmacology of corticosteroids. Respiratory Care, 63(6), 655–670. https://doi.org/10.4187/respcare.06314
3. Gupta P, Bhatia V. Corticosteroid physiology and principles of therapy. Indian J Pediatr 2008;75(10):1039–1044.
4. Shaikh S, Verma H, Yadav M, Jauhari M, Bullangowda J, Applications of steroid in clinical practice: a review. ISRN Anesthesiol 2012, vol. 2012, Article ID 985495, 11 pages, 2012. doi:10.5402/2012/985495
5. Ericson-Neilsen, W., & Kaye, A. D. (2014). Steroids: pharmacology, complications, and practice delivery issues. Ochsner journal, 14(2), 203–207.
6. Waljee AK;Rogers MA;Lin P;Singal AG;Stein JD;Marks RM;Ayanian JZ;Nallamothu BK; (n.d.). Short term use of oral corticosteroids and related harms among adults in the United States: Population Based cohort study. BMJ (Clinical research ed.). https://pubmed.ncbi.nlm.nih.gov/28404617/
7. Liu, D., Ahmet, A., Ward, L., Krishnamoorthy, P., Mandelcorn, E. D., Leigh, R., Brown, J. P., Cohen, A., & Kim, H. (2013). A practical guide to the monitoring and management of the complications of systemic corticosteroid therapy. Allergy, asthma, and clinical immunology : official journal of the Canadian Society of Allergy and Clinical Immunology, 9(1), 30. https://doi.org/10.1186/1710-1492-9-30
8. van Staa, T. P., Leufkens, H. G., & Cooper, C. (2002). The epidemiology of corticosteroid-induced osteoporosis: a meta-analysis. Osteoporosis international : a journal established as result of cooperation between the European Foundation for Osteoporosis and the National Osteoporosis Foundation of the USA, 13(10), 777–787. https://doi.org/10.1007/s001980200108 Assessed and Endorsed by the MedReport Medical Review Board
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