A recent study in the British Medical Journal (BMJ) has found that even a single short course of oral steroids can increase the risk of sepsis, blood clots and fractures – so should we be worried? At first glance, we may feel nervous because steroids are a common medication used to treat a wide variety of conditions. In the study 21% of people received at least 1 course of oral steroids over a 3 year period. Most people in the study received steroids for a type of respiratory condition (e.g. upper respiratory tract infection, bronchitis, asthma – 33% in total) followed by ‘spine conditions’ (11%), allergy (10%), connective tissue (5%) and joint disorders (3%). Furthermore, although the numerous long-term side effects of steroids have been characterized, it has often been assumed that occasional short courses of steroids posed little risk – something which this study challenges.
What the study actually shows
But before vowing never to touch another steroid tablet, let us look a little closer – the clue is in the context.
- Every medication has benefits and risks. Although sepsis and blood clots are potentially fatal, so are respiratory conditions (e.g. asthma, bronchitis) and allergy. Connective tissue and joint diseases can result in permanent joint or tissue damage which severely impact people’s health causing immobility and potentially also increasing the long-term risk of sepsis and blood clots. Steroids work by reducing inflammation and are an effective evidence-based treatment for many of these conditions. In fact for COPD (smoking-related bronchitis and emphysema), a comprehensive review of all available evidence concluded that the clear benefit of steroids was “unlikely to be changed by future research”. Looking at the numbers in the BMJ study, the absolute increase in risk of a single steroid course are actually very low. In response to queries about the study, the authors state that a steroid course would need to be given to 141 patients to cause 1 fracture over 1 year. Treating the same number of patients with COPD would help about 15 people. The comparison of risks vs benefits of steroids is even clearer in the case of sepsis and blood clots where many more people would need to be treated to cause 1 adverse event.
- As mentioned in the responses to the study, factors other than steroid use may explain the increased risk of sepsis, blood clots, and fractures. For example, sepsis may be misdiagnosed as bronchitis and only become apparent after steroids are given. The authors have done additional analyses to rule out these confounding factors but whether or not this is sufficient, is a subject of ongoing debate.
- The study was conducted in the USA on a nationwide dataset of private insurance claims of adults 18-64. The differences in the health systems, policies and patient population, means that the study findings may not apply in the UK. For certain diseases (e.g. degenerative disc disease), oral steroids are not included in NICE guidelines but seem to be a mainstream option in the USA. In the peer review document, there was surprise at the prevalence of steroid usage as well as the frequency of prescription by non-specialists and dose used. It may be that these effects are only seen when the drug is misused.
In summary –
This study has stimulated interesting discussion into a previously overlooked area. However the clinical impact in the UK is likely to be limited because as the study authors acknowledge, there is “clear consensus for efficacy” of steroids in many conditions. So even if there were a small increased risk of steroids as suggested by the study, most people would still be better off taking them. Furthermore the study has less relevance in some conditions (e.g. degenerative disc disease) where oral steroids do not form part of NICE guidelines and usual treatment in the UK.
Finally it is important to note that the risk/benefit balance is different for different individuals and not everyone is suitable to be treated according to the guidelines. If you have concerns that you may be especially at risk of particular steroid side effects, discuss these with your doctor.
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Any opinions above are the author’s alone and may not represent those of his/her affiliations. Any comment is based on the best available evidence at the time of writing. All data is based on externally validated studies unless expressed otherwise. Novel data is representative of the sample surveyed. An online recommendation is no substitute for seeing your own doctor and should not be taken as medical advice.
Sources and Further Reading
- Walijee AK et al (2017) Short term use of oral corticosteroids and related harms among adults in the United States: population based cohort study BMJ ;357:j1415 (Online access http://www.bmj.com/content/357/bmj.j1415)
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