Long-Term Steroids: What They Do to the Body and How to Come Off Safely
Corticosteroids are among the most effective drugs in medicine and among the most casually prescribed in India, where steroid-containing combinations are available over the counter and injected for back pain and fever. Understanding what they do over weeks and months is the difference between a useful treatment and a serious harm.
What they are
Synthetic versions of cortisol, the body’s main stress hormone. Prednisolone, dexamethasone, methylprednisolone, hydrocortisone, betamethasone and deflazacort are the common oral and injectable forms.
They suppress inflammation and immune activity powerfully, which is why they work in asthma, autoimmune disease, severe allergy, some cancers and transplant rejection.
Effects of long-term use
Metabolic:
- Weight gain, with fat redistributing to the face, producing a moon face, to the back of the neck as a buffalo hump, and to the abdomen, while the arms and legs thin
- Steroid-induced diabetes, or worsening of existing diabetes
- Raised cholesterol and triglycerides
- Fluid retention, swelling, raised blood pressure
- Low potassium
Bone and muscle:
- Osteoporosis, which begins within the first three to six months. This is why bone protection is started alongside steroids, not after a fracture
- Avascular necrosis, most often of the hip, causing progressive pain and requiring joint replacement
- Proximal myopathy: weakness of the thigh and shoulder muscles, with difficulty rising from a chair or climbing stairs
Immune:
- Increased susceptibility to infection, and masking of its signs, so a serious infection can present with little fever
- Reactivation of tuberculosis, which matters greatly in India, and screening before long courses is appropriate
- Fungal infections, including oral and oesophageal candidiasis, and in some settings mucormycosis, which was seen in the COVID-19 period with uncontrolled sugars and excess steroid use
- Reactivation of hepatitis B and strongyloides
Eyes: cataract, glaucoma, raised eye pressure.
Skin: thinning, easy bruising, purple stretch marks, acne, poor wound healing, excess hair growth.
Gastrointestinal: peptic ulcer risk, markedly increased when combined with NSAIDs.
Psychological: insomnia, agitation, mood swings, euphoria, and occasionally depression or psychosis at high doses.
Children: growth suppression.
Adrenal suppression, the critical point
The adrenal glands stop producing cortisol when an external supply is present. After roughly three weeks of significant doses, this suppression is established and the glands take weeks to months to recover.
Unlock More Content
Watch a short ad to continue reading the rest of this article for free.
Preparing your free unlock…
Two consequences follow.
Never stop abruptly. Sudden withdrawal after prolonged use causes adrenal crisis: severe weakness, vomiting, abdominal pain, low blood pressure, low sodium, collapse. It can be fatal. Doses are tapered gradually, with the rate depending on dose and duration.
Sick day rules. During illness, fever, vomiting, injury or surgery, the body needs more cortisol and cannot make it. Anyone on long-term steroids needs to know to double the dose during significant illness and to seek urgent care if unable to keep tablets down. Carry a steroid alert card and tell every doctor, dentist and surgeon.
Monitoring on long-term steroids
- Blood glucose and HbA1c
- Blood pressure
- Weight
- Bone density, with calcium, vitamin D and usually a bisphosphonate from the outset for courses expected to last three months or more
- Eye examination for cataract and glaucoma
- Screening for latent tuberculosis and hepatitis B before starting long courses
- Potassium and lipids
- Vaccination status, with live vaccines avoided at immunosuppressive doses
Using them more safely
- The lowest effective dose for the shortest necessary time
- Single morning dose, which matches the natural cortisol rhythm and reduces suppression
- Alternate-day dosing where the condition allows
- Local rather than systemic routes wherever possible: inhaled for asthma, topical for skin, intra-articular for a single joint, eye drops. These have far less systemic effect, though high-dose inhaled and widely applied potent topical steroids can still cause systemic effects
- Steroid-sparing agents: methotrexate, azathioprine, mycophenolate and biologics, used specifically so that steroids can be reduced
- Calcium, vitamin D and a bone-protective agent
- Stomach protection where indicated
- Adequate protein and resistance exercise to limit muscle loss
- Salt restriction
Steroid misuse in India
Several patterns cause real harm:
- Steroid injections for back pain, fever and “weakness” given repeatedly in informal practice
- Potent topical steroids sold over the counter and used on the face for fairness or acne, causing steroid-induced rosacea, skin thinning and dependence
- Steroid-containing combination creams for fungal infection, which make the infection worse and widespread while masking it. Recurrent, extensive, atypical ringworm is now a major problem in India and is largely driven by this
- Steroids in unlabelled “ayurvedic” or “herbal” joint remedies, which produce the full Cushingoid picture in people who were never told they were taking a steroid
- Bodybuilding use of anabolic steroids, a different class but similarly unsupervised
If you develop a moon face, weight gain, stretch marks or uncontrolled sugars while taking an unlabelled preparation, consider that it may contain a steroid and tell your doctor.
Coming off
Tapering is individualised. A common approach reduces faster at higher doses and much more slowly below physiological equivalents, with symptoms of adrenal insufficiency watched for: fatigue, nausea, dizziness, joint pain, low mood. Sometimes a morning cortisol or a stimulation test guides the final steps.
This must be done with the prescribing doctor. Neither stopping on your own nor continuing indefinitely because stopping feels bad is safe.
This is general information. Never stop long-term steroids abruptly, never use prescription steroid creams or injections without a doctor, and tell every clinician you see that you are taking them.