Steroid Drug Withdrawal

  • Medical Author:
    Charles Patrick Davis, MD, PhD

    Dr. Charles "Pat" Davis, MD, PhD, is a board certified Emergency Medicine doctor who currently practices as a consultant and staff member for hospitals. He has a PhD in Microbiology (UT at Austin), and the MD (Univ. Texas Medical Branch, Galveston). He is a Clinical Professor (retired) in the Division of Emergency Medicine, UT Health Science Center at San Antonio, and has been the Chief of Emergency Medicine at UT Medical Branch and at UTHSCSA with over 250 publications.

  • Medical Editor: William C. Shiel Jr., MD, FACP, FACR
    William C. Shiel Jr., MD, FACP, FACR

    William C. Shiel Jr., MD, FACP, FACR

    Dr. Shiel received a Bachelor of Science degree with honors from the University of Notre Dame. There he was involved in research in radiation biology and received the Huisking Scholarship. After graduating from St. Louis University School of Medicine, he completed his Internal Medicine residency and Rheumatology fellowship at the University of California, Irvine. He is board-certified in Internal Medicine and Rheumatology.

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Steroid withdrawal facts

  • Synthetic cortisone medications (corticosteroids) simulate cortisol, a naturally occurring, anti-inflammatory hormone produced by the adrenal glands. Such drugs (for example, prednisone) have since benefited many, but are not without potential side effects.
  • The two major problems related to continuous steroid treatment are
    1. drug side effects and
    2. symptoms due to changes in the balance of normal hormone secretion (withdrawal symptoms).
  • The production of corticosteroids is controlled by a "feedback mechanism," involving the adrenal glands, the pituitary gland, and brain, known as the "hypothalamic-pituitary-adrenal axis" (HPAA).
  • Using large doses for a few days, or smaller doses for more than two weeks, leads to a prolonged decrease in HPAA function.
  • Steroid use cannot be stopped abruptly; tapering the drug gives the adrenal glands time to return to their normal patterns of secretion.
  • Withdrawal symptoms and signs (weakness, fatigue, decreased appetite, weight loss, nausea, vomiting, diarrhea, abdominal pain) can mimic many other medical problems. Some may be life-threatening.
  • Tapering may not completely prevent withdrawal symptoms. Steroid withdrawal may involve many factors, including a true physiological dependence on corticosteroids.
  • Patients should carry a list of all their medications in their wallet to alert medical personnel in case of emergency.
  • Supplementation with corticosteroid medication may be needed during periods of stress (such as surgery), even up to a year after stopping corticosteroid therapy.
  • Diagnosis of steroid withdrawal can be difficult. Diagnosis is easier if the patient indicates they have recently stopped or decreased a steroid medication, such as prednisone or prednisolone.
  • Treatment of steroid withdrawal is tailored to the individual. Treatment usually involves steroid administration that is decreased gradually over weeks to months.
  • Physicians who treat steroid withdrawal include primary care physicians, endocrinologists, internal-medicine specialists, and others.
  • The prognosis of steroid withdrawal, if diagnosed early and treated appropriately, is usually good.
  • It is possible to prevent steroid withdrawal by using steroids over short lengths of time. Patients who use steroids for lengthy periods of time may prevent steroid withdrawal by slowly tapering or weaning the dose of the steroid under the direction of a physician.

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Abuse of anabolic steroids has major side effects.

Consequences of Steroid Abuse

It is possible to develop a physiological dependence upon steroids. Taking steroid drugs affects the functioning and hormone secretion pattern of the adrenal glands, since these glands are the source of many natural steroid hormones. For this reason, when doctors prescribe steroids, their discontinuation is always tapered (gradually taking smaller doses) to allow the adrenal glands to return to their normal pattern of function and secretion. Likewise, abrupt discontinuation of anabolic steroid use can also result in withdrawal symptoms that can be dangerous and even potentially fatal.

Introduction to steroids

Research conducted by Edward Calvin Kendall at the Mayo Clinic in the medical use of cortisone lead to a Nobel Prize in 1950. The drug simulated cortisol, a naturally occurring, anti-inflammatory hormone produced by the adrenal glands. Such synthetic corticosteroid drugs (prednisone, prednisolone, and many others) have since benefited patients and are commonly used to treat many conditions, including allergic reactions, asthma, rheumatoid arthritis, and inflammatory bowel disease. They are not without serious drawbacks, however. The two major problems related to continuous, long-term steroid treatment are drug side effects and symptoms due to changes in the balance of normal hormone secretion. The latter typically results from taking doses greater than our body's natural production (about the equivalent of 7.5 mg of prednisone per day). Once patients begin to decrease or discontinue the dose, withdrawal symptoms may occur. Thus, steroids are typically given for the shortest possible time possible. Short-term steroid use is commonly without significant side effects and is often a crucial treatment for a variety of issues, including eczema, allergies, and asthma. Moreover, short-term use does not induce steroid withdrawal.

What are steroid withdrawal symptoms and signs?

Withdrawal symptoms usually appear after extended use of steroids with rapid/sudden stopping of the drug. These steroids include glucocorticoids, anabolic steroids in topical, injectable, and transdermal forms. The following symptoms and signs may occur in individuals that are withdrawing from taking steroids:

Less often, joint pain, skin changes, muscle aches, fever, mental changes, or elevations of calcium may be noted. Dehydration and electrolyte imbalances may occur. Decrease in gastrointestinal contractions can occur, leading to dilation of the intestine (ileus). Steroid withdrawal symptoms mimic many other medical problems.

Discontinuing steroids

Over the years, researchers began to learn why some patients develop symptoms of decreased adrenal function, while others never do. The production of corticosteroids is controlled by a "feedback mechanism," involving the adrenal glands, the pituitary gland, and brain, known as the "Hypothalamic-Pituitary-Adrenal Axis" (HPAA). The continuous administration of corticosteroids inhibits this mechanism, causing the HPAA to "hibernate."

We now know that the amount of the drug needed to suppress the HPAA varies from person to person. As a general rule, using large doses for a few days, or smaller doses for more than two weeks, leads to a prolonged decrease in HPAA function. Typically there are no problems with a 5-day moderately high dose burst of steroids regarding withdrawal symptoms.

Thus, steroid use cannot be stopped abruptly. Tapering the drug gives the adrenal glands time to return to their normal patterns of secretion. (It may take a period of time for things to get completely back to normal). How quickly steroids can be tapered depends on continued control of the underlying disease with decreasing doses, and on how quickly our body adjusts to the need to produce its own hormones. If things go well, four to six weeks (or longer) is a reasonable period.

Unfortunately, tapering may not always completely prevent withdrawal symptoms. Present thinking suggests that steroid withdrawal may involve many factors, including a true physiological dependence on corticosteroids. Further, tests of HPAA function do not always correlate with a patient's symptoms, and these tests are of no value while taking steroids. Therefore, it can be difficult to determine the true cause of a patient's symptoms or reaction to stress (for example, from a disease flare-up, procedure, or surgery). Restarting or increasing dosage may be the only solution.

Taking steroids every other morning gives the body a better chance to recover function. The day without the hormone allows natural stimulation of the hypothalamus and pituitary glands. Thus, alternate-day therapy is ideal, if possible, once the disease is under control. It is still not clear whether new steroids being developed will available to decrease the risks of side effects and HPAA suppression.

We must assume that all patients exposed to steroid therapy for even a short time have diminished HPAA function. Patients who have taken steroids noticing any of the above or other unusual symptoms should notify their doctor. Keep in mind that some medications or alcohol can increase the need for larger steroid doses. You should carry a list of all your medications in your wallet to alert medical personnel in case of emergency. This is especially important if you are receiving steroid therapy or have recently stopped taking steroids. Supplementation may be needed during periods of stress, even up to a year after discontinuing corticosteroid therapy.

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What tests do health care professionals use to diagnose steroid withdrawal?

Because the symptoms of steroid withdrawal are varied and nonspecific, health care professionals may have some difficulty diagnosing this problem. However, the best way to diagnose steroid withdrawal is to have a good history and physical examination from the patient, with emphasis on medications such as steroid usage in the recent past that have been discontinued. The patient can help if they indicate to their doctors they have stopped steroids recently. Other tests that may aid in the diagnosis are the cortisol level, serum calcium level, CBC, electrolyte levels, BUN level, and creatinine level.

What types of doctors treat steroid withdrawal symptoms?

In addition to primary care physicians, internal-medicine specialists, endocrinologists, addiction specialists, emergency physicians, hospitalists, and hospital-based pharmacists can participate in treating steroid withdrawal.

What is the treatment for steroid withdrawal?

In general, steroid withdrawal is treated by administering steroids to decrease or eliminate withdrawal symptoms. Then, gradually decreasing the amount steroids given so the body can adjust to synthesizing steroids normally. Each individual patient is different so the physicians will take into account the patient's symptoms, steroid type (for example, hormonal steroids can be reduced faster than other steroid medications), and the patient's compliance. The weaning time is highly variable and may take a few weeks to up to a year or so depending on the patient's dependency, the strength and type of steroid administered, and underlying medical problems.

Some patients may require increases in their steroids during withdrawal with stressful conditions such as emergency surgery. Such increases are usually very short-term increases.

What is the prognosis of steroid withdrawal?

The prognosis of steroid withdrawal, if quickly recognized and treated, is usually good. The prognosis begins to decline if the steroid withdrawal goes unrecognized and complications such as electrolyte abnormalities, dehydration, and other signs and symptoms lead to further health problems or if the patient becomes noncompliant with treatment protocols.

Is it possible to prevent steroid withdrawal?

Yes, it is possible to prevent steroid withdrawal. The best way to prevent steroid withdrawal is to be sure to use steroids conservatively and for the shortest period possible. Short-term use of steroids (time period varies with the type of steroid and its amount administered -- usually days to weeks) usually does not trigger steroid withdrawal. However, with both short- and longer-term use of steroids, steroid withdrawal may be avoided in most patients by tapering the dose over time. This method may also prevent steroid withdrawal in the majority of patients.

REFERENCES:

Buchman, A.L. "Side effects of corticosteroid therapy." J Clin Gastroenterol 33.4 Oct. 2001: 289-294.

Encyclopedia Britannica Online; "Medicine in the 20th century - Endocrinology - Cortisone"

Last Editorial Review: 8/2/2017

Reviewed on 8/2/2017
References
REFERENCES:

Buchman, A.L. "Side effects of corticosteroid therapy." J Clin Gastroenterol 33.4 Oct. 2001: 289-294.

Encyclopedia Britannica Online; "Medicine in the 20th century - Endocrinology - Cortisone"

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