Long-term use of oral corticosteroids can cause numerous undesirable effects depending on the dose, duration of treatment and the characteristics of the patient. Examples include fractures (especially vertebral fractures and fractures of the femoral neck), muscle atrophy, increases in glycemia and kalemia, increases in blood pressure, heart failure, open-angle glaucoma, cataracts, psychological disorders and increased susceptibility to infections.
La Revue Prescire1 recently published an overview of measures that can limit the risk of serious adverse effects from long-term use (> 3 weeks) of oral corticosteroids. We thought it would be useful to provide the key messages from that publication. The evidentiary value is almost exclusively limited to ‘expert advice’. There is little data available, and it mainly concerns observational studies.
Measures on which there is consensus:
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The most important measure to limit the risk of unwanted effects is to use the lowest effective dose for the shortest possible time.
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It is useful to inform the patient about the risks of long-term treatment with oral corticosteroids, and especially about the risk of adrenal insufficiency if treatment is stopped too abruptly.
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Before initiating corticosteroid treatment for more than 3 weeks, the following measures are useful.
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Detect the presence of risk factors for adverse effects of corticosteroids. This primarily concerns the presence of risk factors for osteoporotic fractures, diabetes, heart failure, cardiovascular events, glaucoma and psychological disorders.
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Check vaccinations, and in particular the immune status of the patient (and those close to him) for varicella, as this infection may be more serious in immunocompromised patients.
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Several weeks before starting treatment with corticosteroids, check whether administration of a live vaccine is planned.
This mainly concerns the vaccines against measles-rubella-mumps, rotavirus and varicella. In rarer cases, this may involve the vaccines against dengue and yellow fever and the BCG vaccine (see also chapter 12.1. > Special precautions > Immunodeficiency or immunosuppression and vaccination).
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List the medications the patient is taking that may interact with corticosteroids. The following medicines are cited:
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diuretics and laxatives: risk of hypokalemia;
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NSAIDs: increase the risk of gastrointestinal ulcers and water and salt retention;
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bisphosphonates: increased risk of gastrointestinal ulcer;
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atypical antipsychotics and antiandrogens: increase in the risk of hyperglycemia;
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antiepileptic drugs, quinolones and retinoids: increase the risk of depression; ed: for the quinolones there is also the increased risk of tendonitis and tendon rupture;
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antidepressants and dopamine agonists used in Parkinson’s disease: increase the risk of manic episodes.
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The following measures are suggested during treatment.
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Lifestyle adjustments: sufficient exercise, smoking cessation, limiting alcohol consumption, a balanced diet rich in calcium and proteins and avoiding heavy calorie restriction. Exercise has been shown to help maintain muscle strength and bone density in patients receiving long-term corticosteroids.
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Do not administer live attenuated vaccines (wait at least 3 months after the end of corticosteroid treatment).
The Superior Health Council recommends in its advice 9158 of September 2019 with regard to the vaccination of immunocompromised and chronically ill children and/or adults recommends waiting 1 month after stopping high doses of corticosteroids (> 1 mg/kg/day prednisone or equivalent for more than 14 days (children) or > 20 mg/day prednisone or equivalent for more than 14 days (adults)) before to administer a live vaccine.
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Carry out seasonal vaccination (flu, COVID-19 and pneumococcal) and continue to follow up the basic vaccination (DTP).
In the GGR chapter 12.1. > Special precautions > Immunodeficiency or immunosuppression and vaccination, we point out the risk of a reduced immune response and recommend that, where possible, the patient be vaccinated with non-live vaccines at least 2 weeks before the start of treatment with immunosuppressive agents.
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Provide clinical and biological monitoring from the start and subsequently on a periodic basis (e.g. monitoring blood pressure and weight; eye examination at least every 6 to 12 months if there is a risk of chronic glaucoma; monitoring glycemia and kalemia, etc.).
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Measures that are less clear:
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In patients who do not show osteoporosis at the start of corticosteroid treatment, there is no consensus as to which patients should be monitored by osteodensitometry and which patients should receive preventive treatment with bisphosphonates. The guidelines are not clear. On the one hand, bisphosphonates can reduce the fracture risk in certain patients, but we do not know exactly in which patients (insufficient data). On the other hand, some undesirable effects of bisphosphonates potentiate those of corticosteroids, so caution is advised. According to La Revue Prescrire, it seems reasonable to check bone mineral density annually in individuals who are not taking a bisphosphonate.
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It has not been proven that preventive non-pharmacological measures (exercise, avoidance of tobacco and alcohol, calcium-rich diet and exposure to UV light for vitamin D) and pharmacological treatments (calcium-vitamin D) usually recommended to counteract bone loss , fractures can occur.
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The use of PPIs to prevent gastrointestinal ulcers due to corticosteroid treatment is rarely justified. The risk of ulcers from corticosteroids is low, and long-term use of PPIs causes adverse effects, including an increased risk of fractures. However, PPIs are recommended in high-risk patients, such as those receiving concomitant NSAIDs.
Specific sources
1 The Prescrire Review. Prolonged oral corticosteroid therapy. Guidelines to reduce the risk of serious adverse effects. La Revue Prescrire 2023;43:837-43
2024-02-15 19:59:54
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