Complications of Corticosteroid Therapy: A Comprehensive Literature Review

Relevance to Patient Care and Clinical Practice: Corticosteroids are among the most prescribed medications, particularly during the COVID-19 era. The literature has clearly highlighted the dangers of prolonged, high-dose corticosteroid use, which is important for clinicians to consider before treating patients in their clinical practices. Objective: The objective of this article is to review the literature on complications of corticosteroid use, review corticosteroid pharmacokinetics, and provide an updated reference on risks associated with corticosteroid therapy, especially at higher doses. Data Sources: A conventional literature search of PubMed was conducted without restrictions on publication date. Search terms included "corticosteroids," "avascular necrosis," "gastrointestinal bleeding," and "complications." Study Selection and Data Extraction: Pertinent systematic review/meta-analyses and randomized controlled trials were reviewed for study inclusion. Data Synthesis: Corticosteroids were associated with complications including avascular necrosis, gastrointestinal bleeding, myocardial infarction, heart failure, cerebrovascular events, diabetes mellitus, psychiatric syndromes, ophthalmic complications, tuberculosis reactivation, and bacterial sepsis. Increased daily and cumulative doses were associated with increased excess risk of complications. Cumulative doses greater than 430 mg prednisone equivalent were shown to increase the excess risk of avascular necrosis, with progressively higher rates with higher doses. Risk of gastrointestinal bleeding was significantly increased with corticosteroid usage in the in-patient but not out-patient setting. Conclusion: Since corticosteroids have been associated with the aforementioned severe complications and frequent medicolegal malpractice claims, counseling and informed consent should be performed when prescribing moderate-high dosages of corticosteroids. Further research is needed to characterize the long-term effects of corticosteroid usage in COVID-19 patients.