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Steroids: The Downside (Part 2)

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In the first of our three part series on the use of steroids in CLL, I explained what corticosteroids are and discussed the important roles they might play in managing our disease.

In Part 2, we look at the dark side of steroids.

While the breadth and depth of the list of risks might appear daunting, they are just that, risks not certainties, and a patient may never have any problems at all.

I was treated with high dose steroids for more than six months for my ITP (immune thrombocytopenic purpura), but as Glenn Sabin points out in his book, N of 1, we can’t assume anything from one person’s experience.

In this article I will provide a laundry list of adverse event associated with steroid use. In the part 3, we will exam in detail the data about the differentiation of the short- and long-term risks, but in this article, we will use the usual classifications.

Side effects of steroids are, for the most part “on target” results of its potent anti-inflammatory and immune suppressive activity. They are not specifically related to whether you take the steroids for asthma or CLL or as pretreatment for a rituximab infusion.

Potential adverse reactions seen with steroid use include (in order of severity):

Serious adverse reactions include:

  • Severe allergic reaction
  • Suppression of the adrenal glands
  • Cushing syndrome (a disease of too much endogenous or exogenous steroids associated with several stigmata such as a “moon face” and a buffalo hump”
  • Psychosis
  • Myopathy (muscle damage)
  • Infections
  • Diabetes
  • Brain swelling
  • Seizures
  • Low potassium
  • Heart failure
  • High blood pressure
  • Peptic ulcers
  • Gastro-intestinal perforations and bleeding
  • Pancreatic inflammation
  • Bulging of the eyes (exophthalmos)
  • Tendon rupture
  • Bone death (osteonecrosis)

Serious adverse reactions seen with long-term steroid use include:

  • Cataracts
  • Glaucoma (increased pressure in the eye)
  • Growth suppression (in children)
  • Immune suppression
  • Kaposi sarcoma (a rare skin cancer seen more commonly in those with suppressed immunity)
  • Withdrawal symptoms if discontinued abruptly

Most common (often defined as >10%) adverse reactions seen include (note some overlap):

  • Increased blood pressure
  • Fluid retention and edema
  • Low potassium
  • Upset stomach, including nausea and vomiting
  • Muscle loss
  • Skin thinning, redness, and other changes
  • Impaired wound healing
  • Easy bruising
  • Acne
  • Abnormal hair growth
  • Insomnia
  • Depression, anxiety and mood swings
  • Menstrual irregularities
  • Weight gain and increased appetite

This list is not complete. It serves as reminder as to why we should always try to use as low a dose for as short a time as possible to avoid any of these potential problems.

More on steroids in the next segment.

Brian Koffman, MD 5/2/17

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