Do Doctors Know Short Term Steroids Are NOT Always Safe?

We suspect that most health professionals now realize that corticosteroids (aka steroids, cortisone, prednisone, etc.) have a laundry list of serious side effects when taken for long periods of time. There is, however, an assumption that when physicians prescribe short term steroids in a “dosepak,” there are few, if any complications. That article of faith is now being challenged by researchers.

One reader shares her experience with methylprednisolone (Medrol):

Q. I was given a Medrol dose pack for a rash that developed following gallbladder surgery. (I was highly allergic to the glue used to seal the incision.)

I picked up the script in the evening and took the pills before going to bed. That was the biggest mistake of my life! The severe adverse reactions began the next day and did not slow down for months. Five years later, I still suffer from the after-effects of this steroid.

I had every side effect imaginable—insomnia, severe fatigue, muscle weakness that interfered with walking, muscle spasms, shooting pains all over my body, high blood pressure, anxiety, increased blood sugar levels, depression, heart palpitations, ulcer, sprained ankle and tendinitis in my foot. Why don’t doctors warn you about adverse effects?

A. Methylprednisolone (Medrol) is a powerful corticosteroid. The Dosepak you received provides a loading dose that is gradually tapered over several days.

Doctors often prescribe a short course of treatment with drugs like prednisone or methylprednisolone to treat serious inflammation. This kind of “burst” dosing is used for rashes, back pain, sinusitis, bronchitis and a range of allergic reactions.

Many health professionals assume that such steroid treatment is very safe. But the reactions you describe are not uncommon. More details about the complications in a moment. But first…

A VERY Short History of Corticosteroids:

Cortisone was introduced as a treatment for rheumatoid arthritis in 1948. It was one of those discoveries that changed modern medicine. In 1950, Mayo Clinic physician Philip Hench and his chemist colleague, Edward Kendall, shared the Nobel Prize for Physiology and Medicine with Swiss chemist Tadeus Reichstein. It is rare to have a discovery lead to a Nobel Prize so quickly.

Doctors were excited about the extraordinary improvement cortisone produced for patients with symptoms of rheumatoid arthritis. Many of the patients in the early report would say something like “I’ve lost half of my rheumatism” (Archives of Internal Medicine, April 1950). 

Steroid Side Effects:

Despite the initial steroid excitement, the early clinicians noted undesirable reactions. Side effects that surfaced included fluid retention, insomnia, euphoria, depression, increased appetite, hypertension, elevated blood sugar and moon face.

Even with these adverse reactions, there was tremendous enthusiasm surrounding corticosteroids for rheumatoid arthritis. It led to widespread prescribing of drugs such as cortisone, dexamethasone, prednisone and prednisolone. People who were bedridden and needed wheelchairs or crutches were able to walk and even climb stairs for the first time in years.

Gradually, though, additional complications came to light. Doctors began observing that long-term use of such corticosteroids could lead to ulcers, cataracts, glaucoma, diabetes, osteoporosis, infections, cardiovascular disease and muscle weakness.

Do Short Term Steroids Eliminate Side Effects?

Fast forward to the 21st century. Doctors prescribe drugs like prednisone and methylprednisolone in short courses or “bursts” to treat a wide variety of inflammatory conditions. These range from eczema and contact dermatitis to sinusitis, sore throat and bronchitis. The assumption is that few patients will develop serious adverse reactions in the 10 days to two weeks they take these medicines.

Research, however, challenges the safety story of treatment with short term steroids. Investigators in Taiwan analyzed data from that country’s National Health Insurance Program (Annals of Internal Medicine, July 7, 2020). 

More than 2.6 million people received at least one burst of corticosteroid treatment over a three-year period. The scientists noted that within 5 to 30 days of the short steroid exposure, people were at increased risk for gastrointestinal bleeding, sepsis [“blood poisoning”] and heart failure. The chances of these serious consequences approximately double when a patient takes short term steroids.

The authors note that doctors are well aware that:

“long-term treatment with oral corticosteroids is associated with various adverse effects, such as infections, gastrointestinal (GI) bleeding or ulcers, cardiovascular diseases, Cushing syndrome, diabetes and metabolic syndrome, cataracts, glaucoma, and osteoporosis.”

They point out that few studies have looked into the possibility of adverse effects associated with short term steroids. These Taiwanese investigators had access to the entire National Health Insurance Research Database. This resource allowed them to examine the medical records for the entire country. It was established in 1995 and represents 99.6% of the Taiwanese population.

Here is how they describe their research:

“This study shows several key findings. First, steroid bursts [short term steroids] are commonly prescribed in the general adult population in Taiwan, because 25% of adults received steroid bursts during the 3-year study period. Second, the most common indications for steroid bursts are skin disorders and respiratory tract infections. Third, the highest risk for GI bleeding, sepsis, and heart failure occurs within the first month after receipt of the steroid burst, and this risk is attenuated during the subsequent 31 to 90 days.”

Please reflect on this observation. In Taiwan, one quarter of the population received short term steroids over the three years of the study. That’s extraordinary.

We doubt that people in the US receive corticosteroids to such an extent. But we imagine a great many doctors do prescribe short term steroids for a wide variety of conditions, including allergies, asthma, rheumatoid arthritis, skin rashes like poison ivy, upper respiratory tract infections, bronchitis, sinusitis and back pain. We suspect that many patients may not be told about all the potential complications of short term steroids because doctors think they are relatively harmless.

The Taiwanese authors caution their colleagues that:

“Physicians who consider prescribing steroid bursts should weigh the benefits against the risks for rare but potentially serious adverse events.”

An editorial in the same issue of the Annals of Internal Medicine (July 7, 2020) notes that this is:

“the largest study to date examining the risks of short-term corticosteroid use. The large sample size allowed investigators to detect small but significant increases in 3 major AEs [adverse events] associated with corticosteroids. On the basis of the risk differences reported, the 4 million patients exposed to corticosteroid bursts experienced 41,200 gastrointestinal bleeding events, 400 cases of sepsis, and 4000 cases of new heart failure per year that were directly attributed to this brief exposure.”

The authors go on to note:

“Medication-related risks for AEs [adverse events] can, of course, be outweighed by major treatment benefit. However, this study and prior work show that corticosteroid bursts are frequently prescribed for self-limited conditions, where evidence of benefit is lacking.” 

Consequently, many people are exposed to potential harm, including heart attack, stroke, deep vein thrombosis and bone fracture for conditions that generally clear up on their own.

The authors of the editorial urge their medical colleagues to be thoughtful when they consider short corticosteroid “bursts” for minor ailments, especially when there is a lack of evidence for meaningful benefit. They state that as little as three days of exposure could increase the risk for serious adverse reactions.

Balancing the Benefits and Risks:

I am not totally objective about the benefits and risks of corticosteroids. Many years ago I went deaf in one ear overnight. My ear, nose and throat physician prescribed a short course of corticosteroids. And yes, they did have side effects. I was jittery and very irritable. Just ask Terry and she will tell you that I was not fun to be around. And I could not sleep for a couple of days. I just felt weird. 

But, by the end of the course of corticosteroids my hearing started to come back. Now I won’t tell you that I hear well. But I can hear in both ears. That is pretty important for someone who relies on his hearing to do a syndicated show on public radio.

Were the side effects worth it? In my case, absolutely! Would I  take a Dosepak again? If the situation called for it, absolutely! But I agree with the researchers from Taiwan. Minor or self-limited conditions should not be treated with powerful steroids unless there are extenuating circumstances.

Readers Share Stories About Adverse Reactions from Short Term Steroids:

Betty did not respond well to prednisone prescribed for poison ivy:

“Prednisone given to me by a medical doctor for poison ivy rash resulted in a terrible headache and raised my blood pressure to dangerous levels. I do not ever take prednisone for rashes.”

Mary had serious complications from short term steroids. In her case it was methylprednisolone:

“I was prescribed the methylprednisolone dose pack in the ER for severe headache caused by whiplash. On the fifth day, I went back to the ER with a pounding heart and chest pain. My BP was 179/96.

“It was an anxiety attack. I stopped the methylprednisolone early, not taking the last 2 pills. My WORST side effects were high blood pressure, heart palpitations, rapid heart rate, insomnia, nausea and lack of appetite. I am now three weeks past my last dose, and I have seen my doctor twice. I have also seen a cardiologist, who has done a slew of tests. I am finally getting some sleep, and my bp is normal again. But I am still not feeling well, and my biggest issue right now is my elevated heart rate. This medicine is now listed on my chart as causing a serious adverse reaction. I wish I had read these forums before taking this Devil Drug!”

Ella was prescribed prednisone for sudden hearing loss. It can help. It saved my hearing. But there is a price to be paid:

“I’ve been on prednisone for 2 weeks now for sudden hearing loss in one ear. At my last doctor visit I was given another prescription for 2 more weeks to eventually taper off the drug. I am so ready to be off of this drug. The side effects are awful: I have difficulty focusing, brain fog and a jittery shaky inside feeling. I get irritated by things I’m not normally irritated by. I am also having trouble sleeping.”

Sara shares the psychological effects of short term steroids:

“I was prescribed 50mg of prednisone for 10 days without a taper. By day 3 I fell into a deep depression. I couldn’t eat, I couldn’t sleep and my body was in pain. I had no motivation to move. I laid on my bathroom floor crying. I wanted to end my life. I had a feeling of no escape.

“I had no idea what was happening to me until I searched side effects of prednisone and realized what it was. I stopped taking it and it took me about 3 weeks to finally return to myself. I still have bouts of anxiety 5 months later after what I had gone through on that medication. Never again!”

When Short Term Steroids Can Make Sense:

People who suffer from chronic inflammatory diseases such as asthma, rheumatoid arthritis or colitis sometimes have severe flareups that can be disabling. The editorial in the Annals of Internal Medicine observes that in such cases a short course of corticosteroids “…may prevent disability, preserve function, and maintain quality of life.”

Donna shares this positive prednisone story:

“There’s poison ivy, and there’s POISON IVY! My husband gets a barely noticeable itchy rash that doesn’t impact his daily life in any measurable way. When I get poison ivy, I swell like a balloon; the blisters are the size of half golf balls; and when they finally start draining, it takes days for the draining to stop.

“Twice in my life prior to finally going to the doctor for help, I spent over a week in bed, only getting up to use the bathroom, which was agony. A typical course of poison ivy would last over two weeks. Prednisone is a life-saver for me, almost to the point of calling it miraculous.”

In light of the new research, though, physicians and patients will need to carefully balance the benefits and risks of corticosteroids for relatively minor ailments. Even when such drugs are prescribed for just a few days there can be serious adverse events.

Should you wish to learn more about corticosteroids, here is a link to a comprehensive article:

Prednisone Side Effects: Deal With The Devil?
Prednisone is a valuable medication for many serious conditions, but prednisone side effects can be serious, including sepsis and psychological reactions.

Share your own story about the use of short term steroids in the comment section below. We would like to learn about all sorts of experiences, either positive or negative.

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