Steroid Side Effects: Recommended Monitoring and Intervention

Some of the more common side effects of long-term steroid administration are listed in Table 2. It is important to note that different people will have very different responses to steroids. The key to successful steroid management is to be aware of the potential side effects and work to prevent, or reduce, them where possible. Reduction in steroid dose may be necessary if side effects are unmanageable or intolerable (Figure 4). If this is unsuccessful, changing to another type of steroid or dosing regimen is necessary before abandoning treatment altogether. This should be done with your NMS.

Table 2: Steroid side effects

Steroid side effectAdditional InformationDiscuss with your NMS
Weight gain and obesityYou should be warned that steroids may increase appetite; dietary advice should be provided before starrting steroids.It is important that the whole family eat sensibly in order to prevent excess weight gain. Healthy eating plans can be designed in discussion with a dietary expert and your medical team
Cushingold features (“moon face”)Fullness in face and cheeks may become more noticeable over timeCareful monitoring of diet, minimizing sugar and salt will help with weight gain and may help to minimize Cushingold features
Excessive growth of hair on the body (hirsuitism)Steroids often cause excessive har growth on the bodyThis is not usually severe enough to warrant a change in medication
Acne, fungal infections of the skin (tinea), wartsThis may be more noticeable in teenagersUse specific treatments (topical prescription) and do not rush to change steroid regimen unless there is emotional distress
Short statureHeight should be checked at least every 6 months as part of general careIf growth has slowed or stopped, or if height increase is <1.5 inches (4cm)/year, or if height is < 3rd percentile, referral to endocrine specialist may be necessary
Delayed pubertyPuberty should be checked at each visit beginning at 9 years old

Tell you NMS about any family history of delayed sexual maturation

Testosterone replacement therapy is generally recommended for boys who have not started puberty by age 14

If you are concerned about delayed pubertal development, or if puberty has not started by age 14, referral to an endocrine specialist for evaluation may be necessary
Adverse behavioural changesTell your NMS about any baseline mood, temperment, and ADHD issues

Be aware that these often temporarily worsen in the initial six weeks on steroid therapy

Baseline behaviour issues should be treated prior to starting steroid therapy, e.g. ADHD counselling or prescription

It may help to change the timing of steroid medication to later in the day – discuss this with your NMS, who may also consider a behavioral health referral

Immune suppressionTaking steroids may reduce immunity (the ability to fight infections). Be aware of risk of serious infection and the need to promptly address minor infectionsObtain chicken pox immunization prior to starting steroid therapy; if not done seek medical advice if in contact with chicken pox

If there is a regional problem with tuberculosis, there may need to be specific surveillance

Adrenal suppressionInform all medical personnel that you are taking steroids, and carry a steroid alert card

It is very important that steroid doses are not missed for more than 24 hours, as this may cause adrenal crisis

Know when stress dose steroids should be given (severe illness, major trauma or surgery) to prevent adrenal crisis

Know the signs and symptoms of adrenal crisis (stomach pain, comiting, lethargy)

Have a prescription for hydrocortisone intramuscular injection at home (you may need to know how to administer in case of adrenal crisis)

Never stop taking steroids abruptly

Ask you NMS for astress dose steroid plan that explains:

  • What to do in the case of a missed steroid dose > 24 hours (because of fasting, illness, or prescription unavailability)
  • When to give stress dose steroids, at what dose, and in what form (by mouth, by intramuscular injection or by IV); consult the PJ Nicholoff Steroid Protocol for an example plan:
  • If you are going to stop taking steroid medications, ask your NMS for tapering plan, They can refer to the PPMD PJ Nicholoff Steroid Protocol for an example plan:
High blood pressure (hypertension)
Your blood pressure (BP) should be checked at each clinic visitIf BP is elevated, reducing salt intake and weight reduction may be useful first steps

If ineffective, your primary care provider may consider additional medication

Glucose introleranceYour urine should be tested for glucose (sugar) with dipstick test at clinic visits

Tell your NMS about increased urine or increased thirst

Blood test should be done once a year to monitor for development of type 2 diabetes and other complications of steroid-induced weight gain

Further blood tests for type 2 diabetes may be needed if urine tests or symptoms are positive for glucose
reflux (GERD)
Steroids can cause reflux symptoms (heartburn). Tell your NMS if you have these symptomsAvoid non-steroidal anti-inflammatory drugs (NSAIDs) such as aspirin, ibuprofen, naproxen

Antacid can be used for symptoms

Peptic ulcer
Report symptoms of stomach pain as this can be a sign of damage to the lining of the stomach

Your stool can be checked for blood if you are anemic or if there is suspicion of bleeding in the gut

Avoid NSAIDs (aspirin, ibuprofen, naproxen)

Prescription medications and antacids can be used if
you are having symptoms

You may need to see a gastrointestinal (GI) physician for evaluation and treatment

CataractsSteroids can cause benign cataracts; evaluation with an annual eye exam is neededConsider switching from deflazacort to prednisone if cataracts evolve that affect vision (deflazacort has been shown to have a higher risk of cataract development)

If cataracts are present, an ophthalmology consultation may be needed

Cataracts will only need to be treated if they interfere with vision

OsteoporosisTell your NMS about fractures and back pain at each visit

Spine X-rays should be done every 1-2 years to monitor for vertebral compression fractures

DEXA every 2-3 years to monitor bone density

Yearly vitamin D blood levels should be checked using a 25 OH vitamin D test (ideally late winter in seasonal climates): vitamin D supplements with vitamin D3 may be needed if levels are low

Your diet should be evaluated each year to make sure you are eating/ drinking adequate amounts of calcium

Vitamin D supplements may be needed depending on level in blood

Check 25 OH vitamin D levels annually; supplement as needed

Make sure that your dietary calcium intake meets recommendations for your age

Calcium supplements may be needed if your diet does not include adequate amounts of calcium

Weight-bearing activities (standing) can be helpful for bone health

Discuss with your NMS/PT before starting an exercise/ weight bearing program

(Urine looks reddish-brown coloured because it contains breakdown products of muscle proteins. This needs to be tested for in a hospital lab.)
Report any reddish-brown urine to your NMS Urine can be tested for myoglobin Urine should also be checked for infectionAvoid vigorous exercise and eccentric exercises, such as running downhill or trampolining

Good fluid intake is important

Kidney investigations are needed if it this continues