Chronic steroids and analgesic usage and side effects
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Chronic Steroids & Analgesics: Uses and Side Effects
PART 1 — CHRONIC CORTICOSTEROIDS (Glucocorticoids)
Mechanism
Corticosteroids exert a pluripotent anti-inflammatory effect via inhibition of inflammatory mediator gene transcription. The goal of therapy is to suppress disease activity with the minimum effective dosage. Side effects are dose- and duration-dependent, and typically appear at >10 mg/day of prednisone (or equivalent).
— The Washington Manual of Medical Therapeutics
Side Effects by System
🔴 Endocrine
| Effect | Details |
|---|---|
| Hyperglycemia | Common; can precipitate or worsen diabetes |
| Weight gain / Cushingoid features | Central obesity, moon face, buffalo hump |
| Adrenal suppression | Assumed with >20 mg prednisone (or equivalent) for >3 weeks; can lead to adrenal crisis during major stress (surgery, infection) → treat with stress-dose glucocorticoids |
| Osteoporosis | Start calcium 1–1.5 g/day PO + vitamin D 1000 units/day PO as soon as steroid therapy begins; bisphosphonates for prophylaxis |
🔴 Cardiovascular
- Dyslipidemia
- Hypertension
🔴 Ophthalmologic
- Posterior subcapsular cataracts
- Glaucoma (raised intraocular pressure)
🔴 Immunologic
- Reduced resistance to infections — major cause of morbidity and mortality
- Minor infections can become systemic; quiescent infections (TB, fungi) can reactivate
- Local/systemic signs of infection may be partially masked
- Consider Pneumocystis jirovecii (PCP) prophylaxis in patients on prednisone ≥20 mg for >1 month
🔴 Dermatologic
- Acne
- Easy bruising / purpura
- Cutaneous atrophy (skin thinning)
🔴 Psychiatric
- Spectrum from mild nervousness, euphoria, insomnia → severe depression or psychosis
🔴 Musculoskeletal
- Proximal myopathy — muscles not tender; CK, aldolase, and EMG typically normal; resolves slowly after discontinuation
- Avascular (ischemic) necrosis of bone — most commonly femoral head, humeral head, tibial plateau
— The Washington Manual of Medical Therapeutics, p. 975
Prevention Strategies for Steroid Side Effects
| Complication | Prevention |
|---|---|
| Adrenal suppression | Single daily dose of short-acting agent (e.g., prednisone) |
| Osteoporosis | Calcium + Vitamin D from day 1; bisphosphonates; weight-bearing exercise; avoid alcohol/tobacco |
| PCP pneumonia | Trimethoprim-sulfamethoxazole if ≥20 mg/day prednisone for >1 month |
| Hyperglycemia | Monitor blood glucose; adjust hypoglycemic agents |
PART 2 — CHRONIC ANALGESIC USE & Side Effects
NSAIDs (Non-Steroidal Anti-Inflammatory Drugs)
| System | Side Effects |
|---|---|
| GI | Dyspepsia, peptic ulcer disease, GI bleeding (inhibit prostaglandin-mediated mucosal protection) — use PPI prophylaxis in high-risk patients |
| Renal | Renal papillary necrosis, chronic interstitial nephritis, fluid retention, hypertension; can precipitate acute kidney injury in volume-depleted patients |
| Cardiovascular | Increased risk of MI and stroke, especially COX-2 selective agents; hypertension |
| Hematologic | Platelet dysfunction → prolonged bleeding time |
| Hepatic | Hepatotoxicity (especially diclofenac) |
| Analgesic nephropathy | Long-term mixed analgesic use (especially with acetaminophen combinations) → chronic tubulointerstitial nephritis |
Acetaminophen (Paracetamol)
| Side Effect | Details |
|---|---|
| Hepatotoxicity | Dose-dependent; safe at therapeutic doses but toxic accumulation occurs with >4 g/day in healthy adults, or lower doses in alcoholics/fasting/hepatic disease |
| Analgesic nephropathy | Chronic use associated with chronic kidney disease, especially when combined with other analgesics |
Opioids (Chronic Use)
| System | Side Effects |
|---|---|
| CNS | Sedation, cognitive impairment, hyperalgesia (paradoxical increased pain sensitivity with long-term use) |
| GI | Opioid-induced constipation (most common, does not resolve with tolerance), nausea/vomiting, ileus |
| Endocrine | Opioid-induced androgen deficiency (OPIAD) — hypogonadism, decreased libido, erectile dysfunction, amenorrhea, osteoporosis |
| Immune | Immunosuppression |
| Respiratory | Respiratory depression (dose-dependent) |
| Dependence/Tolerance | Physical dependence, tolerance, and addiction risk with chronic use |
| Withdrawal | Abrupt discontinuation causes: anxiety, myalgias, diaphoresis, diarrhea, piloerection |
Neuraxial Analgesics (Epidural/Intrathecal)
Side effects from neuraxial opioids and local anesthetics include:
- Pruritus (most common with neuraxial opioids)
- Urinary retention
- Nausea/vomiting
- Respiratory depression (delayed, especially with morphine)
- Hypotension (local anesthetics)
— Miller's Anesthesia, 10e
Summary Table: Chronic Use Toxicities at a Glance
| Drug Class | Key Chronic Toxicities |
|---|---|
| Corticosteroids | Osteoporosis, adrenal suppression, hyperglycemia, immunosuppression, myopathy, AVN, cataracts, psychiatric effects |
| NSAIDs | GI ulcers/bleeding, renal impairment, cardiovascular risk, analgesic nephropathy |
| Acetaminophen | Hepatotoxicity, nephropathy |
| Opioids | Constipation, hyperalgesia, endocrine dysfunction, dependence, immunosuppression |
Sources: The Washington Manual of Medical Therapeutics; The Harriet Lane Handbook, 23rd ed.; Miller's Anesthesia, 10e
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