Corticosteroids - oral
Exam Tips
- Prednisolone is the usual UK oral first-line anti-inflammatory steroid; fludrocortisone is primarily mineralocorticoid.
- High-potency long-acting agents (dexamethasone, betamethasone) have minimal sodium-retaining action and are useful when fluid retention is undesirable.
- Never stop long-term oral steroids suddenly; think HPA-axis suppression and tapering strategy.
- Live vaccines are contraindicated during high-dose immunosuppressive steroid therapy and should be delayed until at least 3 months after stopping.
- In systemic sclerosis, prednisolone doses >=15 mg/day increase risk of potentially fatal renal crisis, so monitor BP and urine output closely.
Definition
Oral corticosteroids are systemic synthetic adrenal-cortex hormone analogues used in UK practice for anti-inflammatory, immunosuppressive, and replacement indications. Their clinical effects depend on glucocorticoid versus mineralocorticoid activity (for example prednisolone mainly glucocorticoid, fludrocortisone mainly mineralocorticoid), which determines efficacy, adverse-effect profile, and monitoring needs.
Pathophysiology
Oral corticosteroids bind intracellular steroid receptors and alter gene transcription, reducing pro-inflammatory cytokines (for example IL-1, IL-6, TNF-alpha), eicosanoid synthesis, leucocyte migration, angiogenesis, and fibroblast activity. They suppress the hypothalamic-pituitary-adrenal axis via negative feedback on ACTH, so prolonged or repeated courses can cause adrenal suppression and withdrawal risk if stopped abruptly. Glucocorticoid effects include increased gluconeogenesis, protein catabolism, reduced bone formation, and fat redistribution; mineralocorticoid effects increase sodium and water retention with potassium and hydrogen ion loss. Relative potency and sodium-retaining effect differ by agent (see steroid potency tables used in UK prescribing references).
Risk Factors
- Higher dose and longer duration (especially >4 weeks) or frequent rescue courses (>=3/year)
- Children and older adults
- Diabetes mellitus or strong family history of diabetes
- Hypertension, heart failure, renal or hepatic impairment
- Osteoporosis risk or prior fragility fracture
- Past psychiatric illness (including prior steroid psychosis)
- History of peptic ulcer disease or diverticular disease
- Current or previous tuberculosis, untreated infection, or ocular herpes simplex
- Systemic sclerosis (prednisolone >=15 mg/day linked with scleroderma renal crisis risk)
- Concurrent immunosuppressive therapy and incomplete vaccination status
Clinical Features
Symptoms
- Mood change, insomnia, anxiety, irritability, or depressive symptoms
- Increased appetite and weight gain
- Proximal muscle weakness
- Polyuria/polydipsia suggesting hyperglycaemia
- Dyspepsia or abdominal pain
- Recurrent infections or delayed recovery from infection
- Postural dizziness/fatigue if adrenal suppression or withdrawal develops
Signs
- Hypertension and peripheral oedema (more likely with mineralocorticoid activity)
- Cushingoid appearance (moon face, central adiposity, skin thinning, easy bruising)
- Hyperglycaemia
- Proximal myopathy
- Osteoporotic height loss or fragility fracture signs
- Cataract or raised intraocular pressure/glaucoma on follow-up
- Poor growth velocity in children on prolonged therapy
Investigations
Management
Lifestyle Modifications
- Use the minimum effective dose for the shortest feasible duration and review regularly
- Take oral dose in the morning with food where possible to reduce insomnia and GI upset
- Provide steroid treatment card and sick-day rules for intercurrent illness
- Optimise vaccination status before planned long-term/high-dose treatment (inactivated ideally >=2 weeks before; avoid live vaccines during high-dose immunosuppression and for at least 3 months after stopping)
- Bone health measures: weight-bearing exercise, smoking cessation, alcohol moderation, adequate calcium/vitamin D intake
Pharmacological Treatment
Systemic glucocorticoids (anti-inflammatory/immunosuppressive)
- Prednisolone usually 5-60 mg orally once daily depending on indication; use lowest effective dose
- Methylprednisolone typically 2-32 mg orally daily in divided or single doses (indication-specific)
- Dexamethasone often 0.5-10 mg orally daily (higher anti-inflammatory potency, minimal sodium retention)
- Deflazacort usually 6-90 mg orally daily (converted to active metabolite)
- Betamethasone low-dose oral regimens are indication-specific due to high potency
Check contraindications/cautions first: uncontrolled infection, TB risk, glaucoma risk, psychiatric history, diabetes, osteoporosis, peptic ulcer, recent MI, ocular herpes simplex, and systemic sclerosis. Do not stop abruptly after prolonged courses; taper based on dose/duration and relapse risk.
Adrenal replacement regimens
- Hydrocortisone 15-25 mg/day orally in 2-3 divided doses (for adrenal insufficiency replacement)
- Fludrocortisone 50-200 micrograms orally once daily (mineralocorticoid replacement or selected orthostatic hypotension cases)
Hydrocortisone has mixed glucocorticoid/mineralocorticoid action; fludrocortisone has strong sodium-retaining effect, so monitor BP, oedema, and potassium.
Adverse-effect prevention during longer-term therapy
- Proton pump inhibitor such as omeprazole 20 mg once daily when GI risk is high
- Bone protection: alendronic acid 70 mg once weekly when fracture risk indicates
- Calcium/vitamin D such as colecalciferol 800 IU daily (dose per product and deficiency status)
Individualise prophylaxis by age, dose, duration, comorbidity, and co-prescribed NSAIDs/anticoagulants.
Complications
- Adrenal suppression and adrenal crisis risk during abrupt withdrawal or physiological stress
- Serious infection with masked inflammatory signs
- Steroid-induced diabetes or worsening glycaemic control
- Hypertension, fluid retention, and hypokalaemia
- Osteoporosis and fragility fractures
- Peptic ulceration or GI perforation risk (higher with additional risk factors)
- Psychiatric adverse effects including mood disorder, psychosis, and sleep disturbance
- Cataract and glaucoma
- Scleroderma renal crisis in systemic sclerosis (notably with prednisolone >=15 mg/day)
Prognosis
When matched to indication, dose, and duration, oral corticosteroids provide major short-term clinical benefit and can be life-saving in selected conditions. Prognosis is best with structured monitoring, adverse-effect prevention, and safe tapering; morbidity rises with prolonged high-dose exposure, multimorbidity, and poor follow-up.
Sources & References
💊BNF Drug References(42)
- Alclometasone dipropionate[contraindications]
- Alclometasone dipropionate[cautions]
- Beclometasone dipropionate[contraindications]
- Beclometasone dipropionate[cautions]
- Betamethasone[cautions]
- Betamethasone[contraindications]
- Budesonide[contraindications]
- Budesonide[cautions]
- Clobetasol propionate[cautions]
- Clobetasol propionate[contraindications]
- Clobetasone butyrate[contraindications]
- Clobetasone butyrate[cautions]
- Deflazacort[cautions]
- Deflazacort[contraindications]
- Dexamethasone[contraindications]
- Dexamethasone[cautions]
- Fludrocortisone acetate[contraindications]
- Fludrocortisone acetate[cautions]
- Fludroxycortide[contraindications]
- Fludroxycortide[cautions]
- Fluocinolone acetonide[contraindications]
- Fluocinolone acetonide[cautions]
- Fluocinonide[cautions]
- Fluocinonide[contraindications]
- Fluticasone[contraindications]
- Fluticasone[cautions]
- Hydrocortisone[contraindications]
- Hydrocortisone[cautions]
- Hydrocortisone butyrate[cautions]
- Hydrocortisone butyrate[contraindications]
- Methylprednisolone[contraindications]
- Methylprednisolone[cautions]
- Mometasone furoate[cautions]
- Mometasone furoate[contraindications]
- Prednisolone[contraindications]
- Prednisolone[cautions]
- Triamcinolone acetonide[contraindications]
- Triamcinolone acetonide[cautions]
- Triamcinolone hexacetonide[contraindications]
- Triamcinolone hexacetonide[cautions]
- Vamorolone[contraindications]
- Vamorolone[cautions]
✅NICE Guidelines(1)
- Corticosteroids - oral[overview]