Short-Term Systemic Corticosteroids: Appropriate Use in Primary Care
Am Fam Physician. 2020 Jan 15;101(2):89-94.
Author disclosure: No relevant financial affiliations.
Short-term systemic corticosteroids, also known as steroids, are frequently prescribed for adults in the outpatient setting by primary care physicians. There is a lack of supporting evidence for most diagnoses for which steroids are prescribed, and there is evidence against steroid use for patients with acute bronchitis, acute sinusitis, carpal tunnel, and allergic rhinitis. There is insufficient evidence supporting routine use of steroids for patients with acute pharyngitis, lumbar radiculopathy, carpal tunnel, and herpes zoster. There is evidence supporting use of short-term steroids for Bell palsy and acute gout. Physicians might assume that short-term steroids are harmless and free from the widely known long-term effects of steroids; however, even short courses of systemic corticosteroids are associated with many possible adverse effects, including hyperglycemia, elevated blood pressure, mood and sleep disturbance, sepsis, fracture, and venous thromboembolism. This review considers the evidence for short-term steroid use for common conditions seen by primary care physicians.
An analysis of national claims data found that 21% of adults received at least one outpatient prescription for a short-term (less than 30 days) systemic corticosteroid over a three-year period, even after excluding patients who had asthma, chronic obstructive pulmonary disease, cancer, or inflammatory conditions for which chronic steroids may be indicated. The most common diagnoses associated with outpatient prescribing of short-term corticosteroids included (from most frequent to least frequent) upper respiratory infection, spine conditions, allergic rhinitis, acute bronchitis, connective tissue and joint disorders, asthma, and skin disorders.1 Most of these short courses of corticosteroids were prescribed by family medicine and internal medicine physicians.1 Several recent studies have confirmed high rates of prescribing systemic corticosteroids for patients with acute respiratory tract infections, ranging from 11% of all outpatient respiratory infections in a national study 2 to 70% of patients with at least one week of cough in a small study at two urgent care clinics.3 Prescribing oral corticosteroids in short courses may seem to be free from significant adverse effects; however, a large national data set of private insurance claims, which included approximately 1.5 million people, showed that a short course of oral steroids was associated with an increased risk of sepsis (relative risk [RR] = 5.3), venous thromboembolism (RR = 3.3), and fracture (RR = 1.9) in the five to 30 days after steroid initiation compared with those who had not received a short course of steroids.1 The estimated number needed to harm after a short course of steroids was 140 for fracture, 454 for venous thromboembolism, and 1,250 for sepsis. There are also case reports of avascular necrosis developing after even one course of systemic steroids.4,5 It is well understood that short-term systemic steroids can cause hyperglycemia, elevated blood pressure, immunocompromised state, mood and sleep disturbance, and fat necrosis when injected. This review summarizes the evidence base for the effectiveness of short-term systemic (either oral or injected intramuscularly) steroid use in adults in the outpatient primary care setting (Figure 1). This review does not address the role of systemic corticosteroids for conditions where there is a clear consensus supporting effectiveness, such as for asthma and chronic obstructive pulmonary disease exacerbations. This review also does not address localized steroid use, as with joint injection, and topical and inhaled formulations.
SORT: KEY RECOMMENDATIONS FOR PRACTICE
|Clinical recommendation||Evidence rating||Comments|
Single, good-quality RCT and Cochrane reviews of moderate-quality studies
Mixed conclusions from a large, well-designed trial and a systematic review of RCTs
Expert opinion and small clinical trial
Single, good-quality RCT and a meta-analysis with two low-quality RCTs
Two adequately powered RCTs
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Published online December 16, 2019.
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