Are Steroid Bursts Harmful?

Written by Meghan Breed

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The incidence of GI bleeding, sepsis, and heart failure was increased even with a short steroid burst, defined as oral corticosteroids for 14 days or fewer.

Why does this matter?
Steroids are frequently prescribed from the emergency department for a variety of medical conditions, almost reflexively for certain conditions.  In fact, in this population-based study in Taiwan, 25% of the population (age 20 to 64) received at least one steroid burst during the 3-year study period.  A prior population-based cohort study published in the BMJ in 2017 showed increased adverse events following a short steroid burst which included rates of sepsis, venous thromboembolism and fracture. Due to the adverse effects reported in several studies like this, we should probably consider the risk vs. benefit prior to prescribing.

No buffalo humps or cushingoid faces here…just GI bleeding, sepsis, and heart failure
Authors of this study looked at three pre-defined adverse events following a steroid burst – GI bleeding, sepsis and heart failure.  Based on their review of the National Health Insurance Research Database in Taiwan, authors found the incidence rates per 1000 person-years – all steroids prescribed were converted to prednisone equivalents for comparison.  The incidence rates per 1000 person-years among participants prescribed steroid bursts were 27.1 (95%CI 26.7-27.5) for GI bleeding, 1.5 (1.4-1.6) for sepsis, and 1.3 (1.2-1.4) for heart failure. Compared to the cohort without steroids, incidence rates were 16.8 GI bleeding, 1.4 sepsis, and 0.4 heart failure, respectively. Incidence rate ratios (IRRs) for each adverse event, from 5-30 days, were all higher for the cohort prescribed steroids: 1.8 for GI bleed, 1.99 for sepsis, and 2.37 for heart failure. In addition, all IRRs were still increased during the subsequent 31 to 90 days.  Median dose and duration of steroids were actually quite low (10mg and 3 days respectively) as well as mean age (38 years old), particularly if you consider the prescribing pattern for patients with a COPD exacerbation.  Certainly with the incidence of GI bleeding reported in this study, I will make sure to remind my patients to avoid NSAIDs.

As Thomas Davis previously said:
“If the data for steroids are good, this article doesn’t change a thing.
If the data for steroids are weak, this article makes me pause.
If the data for steroids show improvement in quality of life only, I talk to the patient.”

Source
Association Between Oral Corticosteroid Bursts and Severe Adverse Events: A Nationwide Population-Based Cohort Study. Ann Intern Med. 2020 Jul 7. doi: 10.7326/M20-0432. [Epub ahead of print]

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