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The risk of long-term use of oral corticosteroids are well known. This research shows that short "bursts" of one to two weeks also carry some risk of adverse events.
Even short courses of oral corticosteroids such as prednisone and dexamethasone increase the risk gastrointestinal bleeding, sepsis, and heart failure, according to results reported in this week's Annals of Internal Medicine.
The adverse effects of long-term use of corticosteroids are well characterized and common knowledge among physicians, nurses, and many other healthcare professionals. But short "corticosteroid bursts" of one to two weeks have been seen as being relatively safe and an effective way to quell inflammation, particularly for people experiencing a flare-up of a chronic inflammatory conditions. And dexamethasone has been in the news lately because researchers have reported that it substantially cuts the mortality risk of people who are seriously ill from COVID-19.
But this report in the Annals puts corticosteroid bursts in a different light, one in which the benefits are attended by some risk of adverse events, and with the recognition of the drawback the suggestion that they be prescribed only when necessary.
Tsung-Chieh Yao, M.D.,Ph.D., and his colleagues used data from Taiwan's National Health Insurance Research Database to conduct their study. Of the roughly 15.8 million people in the database, about 4 million had received a prescription for at least one corticosteroid burst. For most of their analysis, Yao and his colleagues winnowed that 4 million down to 2.6 million because of various exclusion criteria designed to make the results more reliable,
When Yao et al. compared the people who were prescribed a corticosteroid burst to those who weren't, they found a large difference in GI bleeds (27.1 cases per 1,000 person-years vs. 16.8) and smaller but real differences in sepsis (1.5 cases per 1,000 person-years vs. 1.4) and heart failure (1.3 cases per 1,000 person-years vs. 0.4).
The accompanying editorial by Beth Wallace, M.D., M.Sc., and Akbar Waljee, M.D., M. Sc., of the University of Michigan's Institute for Healthcare Policy and Innovation said the findings mean that for a population of 4 million people exposed to corticosteroid bursts, the short-course of the anti-inflammatory corticosteroids would be associated with 41,200 GI bleeding events, 400 cases of sepsis, and 4,000 new cases of heart failure.
Yao and his colleagues noted how common prescriptions for corticosteroid bursts are in Taiwan (a quarter of the people in the database had received a prescription) and that they are prescribed most often for common skin disorders, such as contact dermatitis and eczema, and upper respiratory tract infections. Short-term use of corticosteroids is not confined to Taiwan problem; the researchers referenced a U.S. study that showed 7% of patients were prescribed short-term courses (less than 30 days) of corticosteroids, most often for upper respiratory tract infections.
As Wallace and Waljee point out, the chance of an adverse event can be outweighed by a medication's benefit. It's a trade-off we are willing to make if the benefit is large enough and occurs often enough. Wallace and Waljee note that corticosteroids prescribed for acute flares of a chronic inflammatory conditions may fend off disability and maintain people's quality of life.
"In contrast," write Wallace and Waljee, "bursts prescribed for self-limited conditions confer no long-term benefit and may not even reduce symptom duration or severity."
Yao and his co-authors make similar points and call for prospective studies or clinical trials to determine the optimal use of corticosteroids by monitoring adverse events.