Glucocortocoids’ potency is double-edged:
while critical in tempering certain disease states, they can
also cause a number of complications.
Corticosteroids have been in use for over 40 years.1-3 Over time
they have become indispensable in controlling a variety of
disease states. Currently, glucocorticoids are available in
numerous formulations: oral, topical, ophthalmic solutions and
ointments, oral inhalers, nasal formulations, parenteral and
rectal preparations. Various complications associated with this
drug class warrant caution and monitoring with each formulation.
This article will address the therapeutic benefits of
glucocorticoids as well as the consequences attributed to oral,
topical and parenteral formulations...
...Musculoskeletal Complications: Glucocorticoids are the most
common cause of drug-induced osteoporosis.13 Glucocorticoids
induce osteoporosis by suppressing intestinal calcium
absorption, decreasing sex hormone production, and inhibiting
bone formation. Approximately one out of five patients treated
for one year with 7.5–10 mg of daily prednisone will develop
skeletal fractures.14 Patients at increased risk are over 50
years of age, postmenopausal, or have restricted mobility.13
All patients requiring long-term glucocorticoid therapy are
candidates for osteoporosis prevention.13 Lifestyle
modifications such as smoking cessation, initiating a
weightbearing exercise regimen, and reducing alcohol consumption
are encouraged in all patients. Calcium (1,500 mg/day) and
vitamin D (800 IU/day) supplementation are also recommended.13
Alternate-day dosing of glucocorticoids does not prevent
osteoporosis. The lowest possible steroid dose should be used,
in order to minimize osteoporosis development.15
Several pharmacological agents are available for the treatment
of glucocorticoid-induced osteoporosis. Thiazide diuretics may
improve calcium absorption and decrease urinary calcium
excretion. Postmenopausal women are encouraged to receive
hormone replacement therapy, provided no contraindications are
present. Men may benefit from testosterone replacement if serum
testosterone levels are low.13 Calcitonin injection and nasal
spray are effective in preventing and treating glucocorticoid-induced
osteoporosis. Bisphosphonates (etidronate, pamidronate,
alendronate) are also used to prevent glucocorticoid-induced
osteoporosis.13,16
Steroid-induced myopathy is a rare effect attributed most often
to fluorinated agents, particularly triamcinolone.2,7 This
complication may be attributed to decreased muscle uptake of
glucose and amino acid in affected muscles. Sudden muscle
weakness is an initial manifestation and muscle wasting may
occur.7 Steroid-induced myopathy is proximal and symmetrical and
may involve both upper and lower extremities.2 Predisposing
characteristics for this complication are unknown.7 There is no
known association between duration or dosage of steroid therapy
and myopathy.2 Steroid-induced myopathy usually resolves upon
steroid discontinuation.2
Avascular necrosis (osteonecrosis) occurs predominantly in
active patients on long-term, high-dose corticosteroids.14
Avascular necrosis is probably secondary to the loading
phenomenon on the hip induced by exercise.14 The most common
site of avascular necrosis is the femoral head.17 Patients may
complain of bone pain or discomfort in the groin.17 Treatment
involves medical management and trauma avoidance in patients
requiring long-term glucocorticoids.14...
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