Critical Care Medicine-Hematologic and Oncologic Disorders>>>>>Complications of Immunosuppressive Drugs and Chemotherapy
Question 1#

Which of the following statements about glucocorticoid toxicity is incorrect?

A. Effects on the eye include cataracts and glaucoma
B. Gastritis and ulcers resulting from glucocorticoids are much more common in patients also taking NSAIDs
C. Immune suppression is dose-dependent
D. Steroid-induced psychosis should prompt a gradual taper
E. A patient taking 8 mg of prednisone a day may be at risk for HPA axis suppression

Correct Answer is D

Comment:

Correct Answer: D

Glucocorticoids have widespread effects on a diverse array of tissue types. Ophthalmologic effects include cataracts and increased intraocular pressure. GI effects include gastritis and ulcer formation and occur synergistically with NSAIDs. Glucocorticoids exert broad immunosuppressive effects on both innate and adaptive immunity in a dose-dependent manner. Psychiatric effects range from confusion to psychosis. Serious psychiatric effects occur in approximately 6% of patients, with the most important risk factor being the steroid dose, though notably the dose is not predictive of the time of onset, type, or duration of symptoms. Treatment of steroid psychosis involves expedited dose reduction when possible and the use of antipsychotic medications as needed. Hypothalamic-pituitary axis suppression is unlikely when patients have received less than 5 mg of prednisone daily for any length of time, likely when patients have received more than 20 mg of prednisone daily for 3 or more weeks, and otherwise is uncertain. 

References:

  1. Skalka HW, Prchal JT. Effect of corticosteroids on cataract formation. Arch Ophthalmol. 1980;98:1773-1777.
  2. Tripathi RC, Parapuram SK, Tripathi BJ, Zhong Y, Chalam KV. Corticosteroids and glaucoma risk. Drugs Aging. 1999;15:439-450.
  3. Piper JM, Ray WA, Daugherty JR, Griffin MR. Corticosteroid use and peptic ulcer disease: role of nonsteroidal anti-inflammatory drugs. Ann Intern Med. 1991;114:735-740.
  4. Franchimont D. Overview of the actions of glucocorticoids on the immune response: a good model to characterize new pathways of immunosuppression for new treatment strategies. Ann N Y Acad Sci. 2004;1024:124-137.
  5. Dubovsky AN, Arvikar S, Stern TA, Axelrod L. The neuropsychiatric complications of glucocorticoid use: steroid psychosis revisited. Psychosomatics. 2012;53:103-115.
  6. Ross DA, Cetas JS. Steroid psychosis: a review for neurosurgeons. J Neurooncol. 2012;109:439-447.
  7. Broersen LHA, Pereira AM, Jørgensen JOL, Dekkers OM. Adrenal insufficiency in corticosteroids use: systematic review and metaanalysis. J Clin Endocrinol Metab. 2015;100:2171-2180.