What are some of the adverse consequences of Glucocorticoids therapy? At what dose (prednisone) does risk increase the most?
- • Glucose intolerance and increased triglycerides attributable to insulin resistance (doses >10 mg/day).
- • Growth suppression in children (less if dose kept ≤0.5 mg/kg).
- • Osteonecrosis (risk at dose >20 mg/day for 1 month).
- • Ophthalmologic: posterior subcapsular cataract formation (risk even at 5 mg/day), glaucoma (>10 mg/day), and central serous choroidopathy (any dose).
- • Skin disorders (bruising, striae, delayed wound repair, hirsutism).
- • Peptic ulcer disease (doses >10 mg/day with nonsteroidal antiinflammatory drugs [NSAIDs] increases risk 3×).
- • Weight gain (>5 mg/day). Up to 25% of patients get Cushingoid on >7.5 mg/day.
- • Infection (doses >20–25 mg/day [≥0.3 mg/kg] cause unacceptable risk).
- • Dose-dependent increased risk starts at >6 to 10 mg/day. Staph Aureus most common.
- • Pneumocystis jiroveci infection increased risk >15 to 20 mg/day for >3 to 4 weeks.
- • Prophylaxis with trimethoprim/sulfamethoxazole (single strength daily or double strength thrice a week) or dapsone (100 mg daily) or atovaquone (1500 mg daily) or monthly inhaled pentamidine (less effective).
- • Prophylaxis should be started sooner and continued longer (even at doses <15 mg daily) if have two or more risk factors: age >60 years, lung involvement from underlying disease (e.g., granulomatosis with polyangiitis, dermatomyositis/polymyositis, etc.), additional immunosuppressive use (e.g., cyclophosphamide, rituximab, antitumor necrosis factor), low CD4 count (<200 cells/μL), lymphopenia (<1000 lymphs/μL).
- • Without multiple risk factors, prophylaxis can be stopped at <15 mg/day.
- • Mycobacterial (especially Mycobacterium tuberculosis ) risk increases at >10 to 15 mg/day for a month.
- • Anergy can occur within 2 to 4 weeks on prednisone 30 mg/day.
- • Fungal: especially Candida.
- • Viral infections, especially herpes (cytomegalovirus, herpes zoster) (>5 mg/day).
- • Hypertension (doses >10 mg/day).
- • Abnormal menstruation (decreased follicle-stimulating hormone and luteinizing hormone) and depressed hormone levels (thyroid-stimulating hormone, testosterone).
- • Mental disturbance (≥20–30 mg/day): rare to occur in children.
- • Muscle weakness (>10–20 mg/day): worse with fluorinated GCs.
- • Osteoporosis (≥5 to 7.5 mg/day for 3 months).
- • Vaccinations: live vaccines safe if on <20 mg/day for adults or <2 mg/kg per day if child weighs <10 kg.
- • Response to vaccines: less response if on >40 mg/day.
- • Allergy skin test results: can be affected by 15–20 mg/day for 2 to 4 weeks.
Pearl: even with short-term use of prednisone (<30 days), up to 20% of patients will experience an adverse event particularly with higher doses or split doses of GCs.
