Glucocorticosteroids: action, indications, forms, side effects and safe withdrawal

Glucocorticosteroids are a group of natural and synthetic hormonal drugs that mimic or enhance the effects of cortisol, the main glucocorticoid hormone produced by the adrenal cortex. The body requires cortisol to respond to stress, maintain metabolism, vascular tone, the immune response, and control inflammation. Glucocorticosteroids are used when rapid and powerful suppression of an inflammatory or immune response is needed. [1]

This group includes hydrocortisone, prednisolone, methylprednisolone, dexamethasone, betamethasone, budesonide, fluticasone, mometasone, clobetasol, and other drugs. They vary in potency, duration of effect, sodium and water retention, route of administration, and risk of systemic side effects. [2]

The term "steroids" in medicine often causes confusion. Glucocorticosteroids are not anabolic steroids for muscle gain; they are anti-inflammatory, immunomodulatory, and replacement drugs used for autoimmune, allergic, inflammatory, endocrine, pulmonary, dermatological, ophthalmological, neurological, and oncological conditions. [3]

The key feature of glucocorticosteroids is their combination of high efficacy and a wide range of risks. In the right situations, they can be life-saving, such as during adrenal crisis, severe asthma exacerbations, anaphylaxis as part of combination therapy, autoimmune inflammation, or cerebral edema. However, when used incorrectly, for long periods, or without proper supervision, they can cause serious complications. [4]

Therefore, the modern prescribing principle is to use glucocorticosteroids only for a clear indication, at the minimum effective dose, for the minimum necessary duration, with a pre-planned monitoring and withdrawal plan. This approach is especially important for systemic therapy with tablets, injections, or intravenous courses, as this is the type most often associated with serious metabolic, bone, infectious, and endocrine complications. [5]

Group of drugs	Examples	The main role
Short-acting	Hydrocortisone	Substitution therapy, acute stress situations
Medium duration	Prednisolone, prednisone, methylprednisolone	Inflammatory and autoimmune diseases
Long-acting	Dexamethasone, betamethasone	Strong and long-lasting anti-inflammatory effect
Inhalation drugs	Budesonide, fluticasone, mometasone	Control of airway inflammation
Nasal preparations	Mometasone, fluticasone, budesonide	Allergic rhinitis, nasal polyposis
Topical skin preparations	Hydrocortisone, mometasone, clobetasol	Dermatitis, eczema, inflammatory skin diseases

How do glucocorticosteroids work?

Glucocorticosteroids penetrate cells and bind to the glucocorticoid receptor. The receptor-drug interaction then influences the activity of numerous genes, reducing the production of pro-inflammatory substances and increasing the synthesis of certain anti-inflammatory proteins. Therefore, the effects of tablets and injections often develop over a period of hours rather than immediately, although more rapid non-genomic effects are possible with higher doses. [6]

Their anti-inflammatory effect is associated with a reduction in the production of cytokines, prostaglandins, leukotrienes, adhesion molecules, and other inflammatory mediators. Furthermore, glucocorticosteroids reduce the migration of immune cells to the site of inflammation, reduce tissue swelling, and suppress the activity of lymphocytes, eosinophils, macrophages, and other immune system cells. [7]

It is precisely because of this broad mechanism of action that glucocorticosteroids are effective against a variety of diseases: they don't treat one specific bacterium or one specific symptom, but suppress the entire inflammatory cascade. This explains why the same drug can be used for rheumatoid arthritis, severe allergies, dermatitis, inflammatory bowel disease, asthma, and some blood disorders. [8]

But this broad spectrum of action has a downside. The same mechanisms that suppress inflammation can also reduce defenses against infections, elevate glucose levels, increase protein breakdown, worsen bone health, promote fluid retention, alter mood, and suppress cortisol production. Therefore, the side effects of glucocorticosteroids are no coincidence: they are directly related to their biological potency. [9]

The dose and duration of treatment are crucial. A short course for an acute illness and months of therapy, even with a relatively small dose, represent different levels of risk, so the physician always evaluates not only the drug name but also the daily dose, duration, route of administration, the patient's age, concomitant illnesses, and other medications. [10]

Mechanism	Beneficial effect	Possible price
Cytokine suppression	Less inflammation and pain	Weaker protection against infections
Decreased lymphocyte activity	Control of autoimmune reactions	Risk of reactivation of latent infections
Reduction of vascular permeability	Less tissue swelling	Masking the symptoms of infection
Effect on glucose metabolism	Energy support during stress	Hyperglycemia and worsening of diabetes mellitus
Effect on bone	No direct benefit with conventional therapy	Osteoporosis and fractures
Suppression of the cortisol axis	Therapeutic effect in cases of excess inflammation	Risk of adrenal insufficiency upon discontinuation

Main forms and methods of application

Systemic glucocorticosteroids are taken orally, administered intramuscularly, or intravenously. They act throughout the body and are used for conditions requiring a general anti-inflammatory or immunosuppressant effect: severe autoimmune diseases, exacerbations of chronic inflammatory diseases, certain allergic and hematological conditions, and replacement therapy for adrenal insufficiency. [11]

Topical forms act primarily where they are applied or injected. These include skin creams and ointments, eye drops, ear drops, nasal sprays, inhalations, intra-articular injections, and soft tissue injections. Their advantage is a lower systemic burden, but with high doses, prolonged use, application to large areas, or the use of strong drugs, systemic effects are still possible. [12]

Inhaled glucocorticosteroids are the mainstay of anti-inflammatory treatment for asthma. The Global Asthma Initiative 2024 update emphasizes that modern asthma management strategies focus on anti-inflammatory disease control, not just rapid bronchodilation. [13]

Cutaneous glucocorticosteroids vary in potency, from mild preparations for the face and folds to very strong agents for dense plaques on the palms, soles, or severe dermatoses. If used incorrectly, they can cause thinning of the skin, spider veins, stretch marks, steroid acne, perioral dermatitis, and systemic absorption, especially in children and when applied under a bandage. [14]

Intra-articular injections are used to locally suppress inflammation in the joint or periarticular area. They can quickly reduce pain and swelling, but should not be used as an uncontrolled, repetitive procedure without a diagnosis, as there is a risk of infection, tissue damage, increased glucose levels, and temporary suppression of the hypothalamic-pituitary-adrenal axis. [15]

Directions for use	Where does it apply?	Typical tasks
Pills	For the whole body	Autoimmune, allergic, inflammatory diseases
Intravenously	Fast and systematic	Severe acute conditions, pulse therapy
Inhalation	Respiratory tract	Bronchial asthma, certain chronic lung diseases
Nasal	Nasal mucosa	Allergic rhinitis, nasal polyposis
Externally on the skin	Leather	Eczema, dermatitis, psoriatic lesions according to indications
Intra-articular	A specific joint	Local inflammation and pain

When are glucocorticosteroids really needed?

Glucocorticosteroids are used when inflammation or an immune response causes more harm than the risk of temporary immune suppression. This may include a severe exacerbation of bronchial asthma, rheumatic disease, autoimmune vascular disease, inflammatory bowel disease, certain neurological conditions, a severe allergic reaction, tissue edema, or the need to replace a deficiency of the body's own cortisol. [16]

In rheumatology, systemic glucocorticosteroids are often used as a "bridge" before disease-modifying antirheumatic drugs (DMARDs) take effect or as a short-term way to quickly control active inflammation. The current approach in this field increasingly favors short courses and lower doses, as chronic use is associated with cumulative side effects. [17]

In pulmonology, inhaled glucocorticosteroids are the primary anti-inflammatory drugs for bronchial asthma, while systemic courses are used primarily during exacerbations or severe cases. This is an important distinction: an inhaled drug for daily control and oral prednisolone for severe exacerbations have different risks and different purposes. [18]

In dermatology, topical glucocorticosteroids remain an important treatment for inflammatory skin diseases, but are selected based on the area, age, severity of inflammation, and duration of treatment. Updated guidelines for atopic dermatitis support the use of topical glucocorticosteroids as part of therapy, but in conjunction with moisturizers, trigger control, and alternative anti-inflammatory agents when indicated. [19]

In adrenal insufficiency, glucocorticosteroids are prescribed not to suppress inflammation, but as replacement therapy to compensate for the deficiency of this vital hormone. This is a fundamentally different regimen: the goal is to approach physiological cortisol levels rather than administer a powerful immunosuppressant dose. [20]

Clinical task	Which form is used more often?	Comment
Rapidly suppress systemic inflammation	Tablets or intravenous administration	A dose reduction plan is needed.
Control bronchial asthma	Inhalation drugs	Fewer systemic effects with proper technique
Treat dermatitis	Topical skin preparations	The choice of strength depends on the zone and age
Treat allergic rhinitis	Nasal preparations	Usually safer than systemic courses
Stop a severe exacerbation	Short systemic course	Should not become a frequent habit
Replace cortisol	Hydrocortisone or prednisolone in a physiological dose	This is not an anti-inflammatory therapy.

Doses, equivalents and duration of action

Different glucocorticosteroids cannot be compared solely on a milligram basis. Approximately 20 milligrams of hydrocortisone, 5 milligrams of prednisone, 4 milligrams of methylprednisolone, and 0.75 milligrams of dexamethasone produce similar anti-inflammatory effects, but differ in duration of action and impact on water-salt balance. [21]

Hydrocortisone is closer to natural cortisol and has a shorter duration of action, so it is often used in replacement therapy and for adrenal crisis. Dexamethasone is longer-acting and more strongly suppresses the hypothalamic-pituitary-adrenal axis, making it more difficult to gently reduce during long-term therapy. [22]

The risk of drug-induced adrenal insufficiency does not only arise with "massive" doses. A 2024 joint guideline from the European Society of Endocrinology and the Endocrine Society indicates that the risk arises with a duration of 3-4 weeks or more if the dose exceeds the physiological equivalent, that is, approximately 4-6 milligrams of prednisone or prednisolone per day. [23]

The daily dose is important, but so is the total exposure: how many weeks or months the person is receiving the drug, whether there have been repeat courses, whether injections, strong cutaneous forms, high-dose inhalations, or a combination of several routes of administration were used. Therefore, the patient should inform the doctor not only about tablets, but also about sprays, ointments, injections, and drops. [24]

The phrase "low dose" does not always mean no risk. For example, even relatively low daily doses of prednisone can be significant for bone tissue when used long-term, and the American College of Rheumatology considers the prevention of steroid-induced osteoporosis in patients receiving 2.5 milligrams of prednisone equivalent or more for more than 3 months. [25]

Preparation	Approximate anti-inflammatory equivalence	Peculiarities
Hydrocortisone	20 milligrams	Short-acting, closer to physiology
Prednisone	5 milligrams	Often used systemically
Prednisolone	5 milligrams	Active form, common drug
Methylprednisolone	4 milligrams	Less mineralocorticoid activity than hydrocortisone
Dexamethasone	0.75 milligrams	Long lasting and powerful action
Betamethasone	0.6-0.75 milligrams	Long action, high activity

Short-term side effects

Even a short course can cause insomnia, increased appetite, irritability, anxiety, increased energy, mood swings, increased blood pressure, fluid retention, heartburn, and elevated glucose levels. In most people, these effects are reversible after completing the course, but in patients with diabetes, hypertension, anxiety disorders, or insomnia, they can be clinically significant. [26]

Hyperglycemia is one of the most important early effects of systemic glucocorticosteroids. These drugs can increase glucose levels, worsen existing diabetes, reveal a hidden predisposition to diabetes, and reduce the effectiveness of hypoglycemic therapy. Therefore, glucose monitoring is necessary in patients at risk. [27]

Psychological reactions can range from mild agitation and insomnia to severe anxiety, depression, hypomania, mania, or psychotic symptoms. The risk is higher at higher doses, but individual sensitivity varies, so the occurrence of unusual behavior, severe insomnia, or dangerous thoughts requires immediate medical attention. [28]

Glucocorticosteroids can mask signs of infection, reducing fever, pain, redness, and the inflammatory response. Therefore, a patient on systemic steroids may appear "better" than the actual severity of the infection, and the physician must be aware of the risk of hidden deterioration. [29]

Short-term therapy is generally safer than long-term therapy, but repeated short courses also add up to a significant burden. If a person is regularly prescribed a "short course" several times a year, this is a reason to reconsider the basic treatment for the underlying condition, such as asthma, dermatitis, or rheumatic disease. [30]

Side effect	When does it happen more often?	What to control
Insomnia	In the first days, especially when taken in the evening	Reception time and sleep
Increased glucose	For diabetes and prediabetes	Glucose, glycated hemoglobin depending on the situation
Increased pressure	In people with hypertension	Home pressure
Irritability and anxiety	At systemic doses	Mood and behavior
Fluid retention	In case of sensitivity to the mineralocorticoid effect	Weight, swelling, pressure
Masking of infection	With any systemic therapy	New symptoms and general condition

Long-term complications

Long-term systemic therapy can lead to osteoporosis, fractures, muscle weakness, increased glucose levels, diabetes, hypertension, weight gain, fat redistribution, skin thinning, bruising, cataracts, glaucoma, infections, sleep disturbances, and mood disorders. The risk depends on the dose, duration, age, concomitant diseases, and other medications. [31]

Steroid-induced osteoporosis is one of the most well-studied complications. Glucocorticosteroids increase bone loss, reduce new bone formation, impair calcium absorption, and can increase the risk of fractures already in the first months of chronic therapy. [32]

The skin and muscles also suffer from the catabolic effects. A person may experience thin, easily bruised skin, purple stretch marks, slow wound healing, bruising, proximal muscle weakness, and difficulty climbing stairs or rising from a chair. [33]

The eyes require special attention. Long-term glucocorticosteroid therapy can increase the risk of cataracts and glaucoma, and topical ocular steroids without ophthalmologist supervision are particularly dangerous because they can increase intraocular pressure and worsen certain corneal infections. [34]

Long-term risks do not mean the drug is always harmful. They mean that if long-term therapy is necessary, a harm-mitigation strategy should be chosen in advance: assessing bones, blood pressure, glucose, infections, vision, body weight, mood, skin, muscles, and the possibility of switching to steroid-sparing treatments. [35]

System	Possible complications	What to track
Bones	Osteoporosis, fractures, osteonecrosis	Densitometry, fall risk, vitamin D
Metabolism	Hyperglycemia, diabetes mellitus, weight gain	Glucose, glycated hemoglobin, weight
Cardiovascular system	Increased pressure, fluid retention	Pressure, swelling, lipids
Leather	Thinning, bruising, stretch marks	Skin examination, wound healing
Eyes	Cataract, glaucoma	Ophthalmological examination
Nervous system and psyche	Insomnia, anxiety, depression, mania	Sleep, mood, behavior

Adrenal insufficiency and withdrawal

With long-term use of glucocorticosteroids, the body can reduce its own production of cortisol. This occurs because the external dose of the drug suppresses the hypothalamic-pituitary-adrenal axis, and the adrenal glands temporarily "adapt" to working less. [36]

If such a drug is suddenly discontinued, especially after weeks or months of treatment, the body's own cortisol levels may not have time to recover. This can lead to weakness, nausea, low blood pressure, dizziness, muscle and joint pain, loss of appetite, hypoglycemia, and, in severe cases, adrenal crisis, which can be life-threatening. [37]

The 2024 joint guidelines of the European Society of Endocrinology and the Endocrine Society consider the risk of adrenal insufficiency to be significant with therapy lasting 3–4 weeks or longer if the dose is above the physiological equivalent. This is an important practical threshold: a long-term course of treatment should not be stopped abruptly simply because “symptoms of the disease have resolved.” [38]

In its 2024 guidance, NICE recommends that when tapering long-term therapy in adults who have been taking glucocorticosteroids for more than 4 weeks, the dose should be initially reduced to a physiological equivalent and then further tapered according to symptom control. NICE also emphasizes that people at risk of adrenal insufficiency should be provided with information on stressful situations, steroid therapy cards, and steps to take when ill. [39]

The withdrawal plan is always individualized. It depends on the underlying disease, dose, duration, medication, rate of previous tapering, withdrawal symptoms, morning cortisol levels, and the risk of exacerbation of the underlying disease. Therefore, independently "cutting" the dose or switching to alternate-day dosing without a doctor's advice can be dangerous. [40]

Situation	The risk of suppressing your own cortisol production
The course is less than 1-2 weeks	Usually lower, but depends on the dose and condition
The course lasts 3-4 weeks or more	The risk becomes clinically significant
The dose is higher than physiological	The risk is higher
Dexamethasone long term	The risk is higher due to the long duration of action.
Refresher courses	The overall risk increases
Strong topical preparations for large areas	A systemic effect is possible
Abrupt discontinuation of a long course of treatment	Risk of withdrawal symptoms and adrenal crisis

Infections and vaccinations

Glucocorticosteroids suppress the immune response in a dose-dependent manner, so the risk of infection increases especially with high doses, long-term therapy, and combination with other immunosuppressants. During treatment, latent infections may reactivate, bacterial and viral infections may become more severe, and inflammatory symptoms may sometimes be alleviated. [41]

Before long-term or high-dose therapy, a physician may assess the risk of tuberculosis, viral hepatitis, human immunodeficiency virus, chickenpox, herpes zoster, Pneumocystis pneumonia, and other infections. The specific scope of testing depends on the disease, dose, duration, region, age, and concomitant immunosuppressant therapy. [42]

Live vaccines require caution. The Centers for Disease Control and Prevention (CDC) notes that high-dose systemic corticosteroid therapy is considered a condition in which a person may be considered moderately or severely immunocompromised; in such situations, live vaccines are generally contraindicated or delayed. [43]

Typically, high-dose immunosuppressive steroid therapy is 20 milligrams or more of prednisone per day, or an equivalent dose, for more than 14 days; for short-course, low-dose, replacement therapy, topical, inhaled, or intra-articular forms, vaccination guidelines may be different. It is best to make the decision before initiating planned immunosuppression. [44]

Inactivated vaccines are generally safer than live vaccines, but the immune response to them may be weaker with high doses of glucocorticosteroids. Therefore, when planning long-term therapy, it is advisable to update vaccinations in advance, especially against influenza, pneumococcal infection, coronavirus infection, and herpes zoster, depending on age and indications. [45]

Question	Practical meaning
High doses of systemic steroids	Increase the risk of severe and opportunistic infections
Long-term therapy	Requires infection risk assessment
Live vaccines	Often contraindicated in cases of significant immunosuppression
Inactivated vaccines	Usually safe, but response may be weaker
Hidden infections	Sometimes it is necessary to identify before treatment
Fever due to steroids	May be less pronounced than usual

Bone protection during long-term therapy

Glucocorticosteroid-induced osteoporosis is one of the most common and clinically important complications of long-term therapy. The American College of Rheumatology's 2022 guidelines address the prevention and treatment of adults and children receiving glucocorticosteroids for more than 3 months at a dose of 2.5 milligrams of prednisone equivalent per day or higher. [46]

Fracture risk assessment should begin early, not after the first fracture. It includes age, gender, dose and duration of therapy, previous fractures, menopause, body weight, smoking, alcohol, family history, risk of falls, comorbidities, and bone density data. [47]

Non-pharmacological prevention includes adequate dietary calcium intake, correction of vitamin D deficiency, regular strength and aerobic physical activity as appropriate, fall prevention, smoking cessation, and alcohol limitation. These measures are helpful, but in those with moderate, high, or very high fracture risk, they are often insufficient without drug prophylaxis. [48]

Medication options include bisphosphonates, denosumab, teriparatide, abaloparatide, and romosozumab, depending on the clinical situation, age, gender, reproductive plans, renal function, and risk level. The specific choice should be made by a physician, as these drugs differ in their mechanism of action, duration, contraindications, and sequential therapy guidelines. [49]

It is especially important to remember about children and young people, for whom long-term therapy may impact growth, bone mineral density, and puberty. NICE recommends regular monitoring of height, weight, pubertal development, and, where appropriate, bone age in children with adrenal insufficiency. [50]

Bone protection measure	To whom is it especially important?
Fracture risk assessment	All with long-term systemic therapy
Densitometry	Adults with long-term risk, according to indications for children
Vitamin D	In case of deficiency or risk of deficiency
Calcium from food	In case of insufficient consumption
Physical activity	For muscles, balance and bones
Drug prophylaxis	At moderate, high or very high risk of fractures
Fall prevention	For the elderly and patients with weakness

Security monitoring

A patient on long-term systemic therapy requires a monitoring plan. Typically, body weight, blood pressure, edema, glucose levels, glycated hemoglobin, lipid profile, signs of infection, skin condition, muscle strength, mood, sleep, vision, fracture risk, and the need for gastrointestinal protection are assessed based on individual indications. [51]

NICE recommends monitoring blood pressure (lying and standing), electrolytes, glycated hemoglobin, bone density in adults during the first 5 years after diagnosis, and lipid profile for people with adrenal insufficiency. Although this guideline specifically addresses adrenal insufficiency, the list clearly illustrates which systems are particularly sensitive to excess or deficiency of glucocorticosteroids. [52]

For people with diabetes or at high risk of diabetes, glucose monitoring should be more vigorous, especially after drug initiation, dose increases, or pulse therapy. Temporary adjustments to glucose-lowering treatment are sometimes necessary because glucocorticosteroids can significantly increase daytime glucose levels. [53]

For patients with ocular risk factors, ophthalmological monitoring is necessary. This is especially important with long-term systemic therapy, topical ocular steroids, a history of glaucoma, diabetes mellitus, high myopia, and symptoms such as blurred vision, eye pain, or the appearance of halos. [54]

Monitoring should be practical. The patient needs to know the dose, the name of the drug, how long the treatment is planned to last, when the follow-up visit is, what tests are needed, what dangerous symptoms are present, and why long-term therapy should not be discontinued without prior approval. [55]

What to control	For what
Blood pressure	Risk of hypertension and fluid retention
Glucose and glycated hemoglobin	Risk of Steroid Diabetes
Weight and waist circumference	Metabolic changes
Lipid profile	Cardiovascular risk
Densitometry	Risk of osteoporosis
Vision	Cataracts and glaucoma
Mood and sleep	Mental and neurological reactions
Infections	Masking of symptoms and immunosuppression

How to reduce harm from treatment

The first way to reduce risk is to determine whether a systemic medication is truly needed. If the disease can be controlled with inhaled, nasal, topical, intra-articular, biologic, or other steroid-sparing therapy, the physician often seeks to reduce the systemic burden. [56]

The second approach is to use the minimum effective dose and plan for tapering in advance. For many inflammatory diseases, glucocorticosteroids should be a temporary bridge or rescue therapy, not the only long-term treatment for disease control. [57]

The third approach is to choose the right time of administration. If the drug is prescribed once a day, it is often taken in the morning to better match the natural cortisol rhythm and to minimize sleep disruption; however, the specific regimen depends on the disease, the drug, and the goal of treatment. [58]

The fourth way is to remember to protect your bones, get vaccinated, and manage glucose, blood pressure, and infections before complications arise. Glucocorticosteroids require not only a prescription but also support: without a preventative plan, even effective therapy can cause long-term harm. [59]

The fifth method is to educate the patient about sick days and stressful situations if there is a risk of adrenal insufficiency. NICE recommends that people at risk of adrenal insufficiency be given information about increasing the dose during physiological stress, medical records, and emergency procedures. [60]

Safety principle	What does this mean?
Minimum effective dose	Do not increase the dose without reason.
Minimum required duration	Don't extend the course "just in case"
Steroid-sparing strategy	Use alternatives if appropriate
Cancellation plan	Do not stop the long course abruptly
Monitoring	Blood pressure, glucose, bones, eyes, infections
Patient education	Understand the danger signs and rules of stressful situations

Children, pregnancy and old age

In children, glucocorticosteroids require special caution because long-term systemic treatment can affect growth, body weight, puberty, bones, mood, and the risk of infections. Even topical medications in young children can be systemically absorbed when applied to large areas, under a diaper, or on broken skin. [61]

In children with asthma, inhaled glucocorticosteroids are often necessary to control airway inflammation and prevent exacerbations, but the dose is adjusted to achieve disease control with the minimum effective dose. Poor asthma control is dangerous in itself, so fear of the word "steroid" should not lead to abandonment of proven anti-inflammatory therapy. [62]

During pregnancy, glucocorticosteroids are used when the expected benefit outweighs the risk, such as in certain autoimmune diseases, asthma, or adrenal insufficiency. The EULAR updated guidelines on antirheumatic drugs state that glucocorticosteroids can be used if needed to control active disease during pregnancy, but treatment should be individualized. [63]

Pregnant women with adrenal insufficiency should not stop glucocorticoid replacement therapy on their own. NICE clearly emphasizes the safety and importance of continuing glucocorticoid replacement therapy during pregnancy in people with adrenal insufficiency, and monitoring should be carried out by a team experienced in this situation. [64]

Older adults have a higher risk of osteoporosis, fractures, diabetes, hypertension, cataracts, glaucoma, infections, sarcopenia, and drug interactions. Therefore, even a moderate dose for several months in an elderly patient requires more active monitoring than the same course in a younger person without risk factors. [65]

Group	Special risks	What is important
Children	Growth, bones, systemic absorption of local forms	Minimum effective dose and growth control
Teenagers	Commitment, body weight, skin, mood	Explaining the benefits and risks
Pregnant women	Balance of disease activity and safety	Command leadership
People with diabetes	Hyperglycemia	Glucose Control Plan
Elderly	Fractures, infections, glaucoma, weakness	Active prevention of complications
Patients on multiple medications	Interactions	Checking all medications

Common mistakes when using

The first mistake is starting systemic glucocorticosteroids without a clear diagnosis. The drug can quickly improve well-being, but simultaneously mask the infection, alter test results, complicate diagnosis, and create the risk of dependence on repeated courses. [66]

The second mistake is using old tablets or injections from your home medicine cabinet for any pain, cough, rash, or allergy. Glucocorticosteroids have specific indications and contraindications, and the same symptom can be a manifestation of an infection, an autoimmune disease, an allergy, a tumor, or a drug reaction. [67]

The third mistake is abruptly discontinuing a long course of treatment. If a person has been taking a systemic drug for several weeks or months, discontinuation should take into account the risk of suppression of the hypothalamic-pituitary-adrenal axis and the risk of exacerbation of the underlying disease. [68]

The fourth mistake is to consider topical medications completely safe. Strong cutaneous glucocorticosteroids, especially with prolonged use on the face, in folds, under dressings, or in children, can cause local complications and systemic absorption. [69]

The fifth mistake is treating side effects without reassessing the steroid load itself. If severe hyperglycemia, fractures, frequent infections, mental symptoms, or severe weakness develop during therapy, it's necessary not only to add new drugs but also to discuss dose reduction, alternatives, and a steroid-sparing strategy. [70]

Error	What is dangerous?	The right approach
Self-medication with pills	Masking of the disease and complications	By appointment only
Abrupt cancellation	Adrenal insufficiency	Reduction plan
Long-term use of strong ointment on the face	Thinning of the skin and dermatitis	Limited course and correct strength
Refresher short courses	Accumulation of risk	Revision of basic treatment
No bone control	Fractures	Risk assessment and prevention
No glucose control	Steroid hyperglycemia	Monitoring and adjustment of therapy

FAQ

Are glucocorticosteroids hormones? Yes. They are drugs that mimic or enhance the effects of cortisol, a natural hormone produced by the adrenal cortex. In medical practice, they are used not only as replacement therapy, but also as powerful anti-inflammatory and immunomodulatory agents. [71]

Are they beneficial or dangerous? They can be both extremely beneficial and dangerous if used incorrectly. Benefits are usually greatest with precise indications, short courses, the minimum effective dose, and monitoring, while risks increase with high doses, long-term use, and self-medication. [72]

Why shouldn't prednisolone be discontinued abruptly after a long course? Because long-term therapy can suppress the body's own cortisol production, and abrupt discontinuation can cause symptoms of adrenal insufficiency or even adrenal crisis. [73]

After what period does discontinuation become risky? The 2024 joint guidelines of the European Society of Endocrinology and the Endocrine Society consider the risk to be significant at a duration of 3–4 weeks or more, if the dose is higher than the physiological equivalent. [74]

What side effects appear quickly? In the first few days, insomnia, increased appetite, irritability, increased blood pressure, fluid retention, heartburn, and increased glucose levels are possible, especially in people with diabetes or prediabetes. [75]

What are the most important complications with long-term use? The most significant are osteoporosis and fractures, diabetes mellitus or worsening of its control, hypertension, infections, cataracts, glaucoma, skin changes, muscle weakness, weight gain, and adrenal suppression. [76]

Should bone protection be considered in all patients on steroids? With long-term systemic therapy, the risk of bone complications should almost always be assessed, and the American College of Rheumatology considers prophylaxis in patients receiving 2.5 milligrams of prednisone equivalent or more for more than 3 months. [77]

Can vaccinations be administered during treatment? Inactivated vaccines are generally acceptable, but the response may be weaker in highly immunosuppressed individuals. Live vaccines are usually contraindicated or delayed during high-dose systemic therapy, so it is best to schedule vaccinations before long-term treatment. [78]

Are inhaled glucocorticosteroids safer than oral tablets? Generally yes, because they act primarily in the airways and have a lower systemic burden, but systemic effects are still possible at high doses and over long periods of time. [79]

Can topical steroid ointments be used long-term? The duration depends on the strength of the drug, the area of application, age, and diagnosis. Strong medications on the face, in folds, in children, and over large areas without supervision increase the risk of skin thinning and systemic absorption. [80]

What is a physiological dose? This is a dose that roughly corresponds to normal daily cortisol production: in adults, NICE lists 15-25 milligrams of hydrocortisone, 3-5 milligrams of prednisolone, or 0.5 milligrams of dexamethasone per day as a physiological equivalent. [81]

What should you do if weakness, nausea, and dizziness occur during withdrawal? You should contact your doctor, as these symptoms may indicate adrenal insufficiency or a worsening of an underlying condition. If your condition is severe, including vomiting, low blood pressure, or confusion, seek immediate medical attention. [82]

Key points from experts

Felix Beuschlein, professor of endocrinology, and the authors of the 2024 joint European Society of Endocrinology and Endocrine Society guideline emphasize that the risk of glucocorticoid-induced adrenal insufficiency depends on the dose, duration, and cumulative exposure, and that recovery of adrenal function varies greatly between patients. The practical takeaway: long-term courses require a tapering and monitoring plan rather than abrupt discontinuation. [83]

Mary Beth Humphrey, MD, and the American College of Rheumatology experts on glucocorticoid-induced osteoporosis emphasize that fracture prevention should begin early in patients receiving long-term therapy, even at relatively low doses. The bottom line: bones need to be protected before a fracture, not after. [84]

NICE experts, who prepared the 2024 guideline on adrenal insufficiency, emphasize the importance of morning cortisol testing, steroid therapy cards, illness plans, and education for patients at risk of adrenal insufficiency. The practical conclusion: the safety of treatment depends not only on the dose, but also on whether the patient knows what to do in the event of infection, surgery, vomiting, or injury. [85]

The Global Initiative for Asthma, in its 2024 report, emphasizes the role of anti-inflammatory therapy in asthma, including inhaled glucocorticosteroids. The practical conclusion: in asthma, it is important not to confuse anti-inflammatory controller treatment with repeated systemic courses, which carry a much greater overall burden. [86]

Daniel Liu, a physician and author of a practical review on monitoring complications of systemic glucocorticoid therapy, emphasizes that side effects are predictable and require active preventive monitoring. The practical conclusion: during long-term treatment, it is necessary to monitor bones, metabolism, blood pressure, infections, eyes, skin, and mental state in advance. [87]