Cortisone and other corticosteroids are powerful anti-inflammatory and immunosuppressive drugs used to treat a wide array of conditions, from autoimmune disorders like rheumatoid arthritis to severe allergic reactions. While often life-saving and highly effective, their use, particularly over extended periods, can lead to serious and potentially irreversible adverse effects. The severity of side effects is generally correlated with the dose and duration of treatment, though some risks can occur even with short-term use.
Musculoskeletal Problems
Osteoporosis and Fractures
One of the most devastating long-term side effects of systemic corticosteroid use is osteoporosis, or bone thinning, which significantly increases the risk of fractures. Cortisone interferes with the body's natural bone-rebuilding process, both increasing bone breakdown and decreasing new bone formation. This effect can be particularly rapid and pronounced, with the greatest rate of bone loss often occurring within the first six months of treatment. The risk is present even at low doses and for relatively short durations, making it a critical concern. Fractures can occur with minimal trauma, leading to chronic pain and significant disability.
Avascular Necrosis
A rarer but equally severe musculoskeletal complication is avascular necrosis (AVN), also known as osteonecrosis. This condition involves the death of bone tissue due to a lack of blood supply, which can lead to the collapse of the affected bone. The hip is the most common joint affected, and the risk increases with higher doses and cumulative exposure. The damage can progress rapidly and may necessitate joint replacement surgery.
Tendon and Cartilage Damage
Repeated cortisone injections directly into a joint or tendon can cause localized damage. This may include weakening and rupture of tendons, particularly in weight-bearing areas. Injections can also damage the cartilage within a joint, especially with frequent use, potentially worsening underlying conditions like arthritis over time.
Endocrine System Dysfunction
Adrenal Insufficiency
Cortisone mimics the body's natural stress hormone, cortisol. When external corticosteroids are taken for more than a few weeks, the adrenal glands, which normally produce cortisol, become suppressed. Abruptly stopping the medication can leave the body without enough cortisol, a life-threatening condition called adrenal insufficiency. Symptoms can include fatigue, nausea, vomiting, low blood pressure, and shock. The steroid dosage must be tapered slowly to allow the adrenal glands to recover.
Corticosteroid-Induced Diabetes
Cortisone can cause a significant increase in blood sugar levels, leading to hyperglycemia or even the development of new-onset diabetes, especially in susceptible individuals. This is particularly problematic for patients with pre-existing diabetes, as it can make managing blood sugar much more difficult. The effect is dose-dependent and typically resolves after treatment is stopped, but careful monitoring is essential.
Neuropsychiatric Complications
Steroid-Induced Psychosis
One of the more alarming, though less common, side effects is the development of psychiatric symptoms, including psychosis, mania, delirium, and severe depression. Corticosteroid-induced psychosis is most likely to occur with high doses (e.g., prednisone >80 mg/day) but can affect 5-18% of patients on corticosteroids. Symptoms may include hallucinations, delusions, paranoia, and severe mood swings. In many cases, symptoms resolve after the medication is tapered or discontinued, but some individuals may require psychiatric medication.
Other Mood and Cognitive Changes
Even at lower doses, cortisone can cause mood swings, anxiety, insomnia, and confusion. These effects are related to the drug's impact on the hypothalamic-pituitary-adrenal (HPA) axis and can be distressing for patients and their families. Older adults are particularly vulnerable to delirium and confusion.
Rare and Severe Complications of Epidural Injections
While generally used for localized pain relief, epidural corticosteroid injections carry a small but serious risk of severe neurologic events. The FDA has issued warnings regarding rare but serious problems, including stroke, paralysis, loss of vision, and even death, when corticosteroids are injected into the epidural space. The effectiveness and safety for this specific use have not been definitively established, and patients should be aware of these potential risks.
Comparison of Short-term vs. Long-term Side Effects
| Feature | Short-Term Side Effects | Long-Term Side Effects |
|---|---|---|
| Common Examples | Facial flushing, insomnia, mood swings, increased appetite, temporary pain flare at injection site | Osteoporosis, avascular necrosis, Cushingoid features, adrenal suppression |
| Severity | Often mild and reversible; flare-ups are temporary | Can be severe, chronic, and sometimes irreversible |
| Dependence | Less dependent on cumulative dose | Strongly dependent on dose and duration of treatment |
| Mechanism | Acute effects related to mimicry of cortisol and local tissue reaction | Chronic disruption of metabolic, endocrine, and immune functions |
| Timeframe | Occur within days or weeks of starting therapy | Develop after weeks to months of continuous use |
| Management | Often resolves on its own; symptomatic treatment may be needed | Requires proactive monitoring and preventive strategies, such as bone density scans |
Conclusion
While cortisone remains a vital medication for managing numerous inflammatory conditions, its potential for severe side effects, especially with long-term use, necessitates careful consideration. The worst effects, including musculoskeletal damage, endocrine suppression, and serious neuropsychiatric issues, highlight the need for a thorough risk-benefit analysis by both patient and doctor. Patients should be fully informed of these risks, receive the lowest effective dose for the shortest duration possible, and be closely monitored for adverse reactions. Never stop cortisone abruptly without medical supervision, as this can trigger a life-threatening adrenal crisis. Proactive management and clear communication with a healthcare team are essential to mitigate risks and ensure safety. For more in-depth information, consult authoritative medical resources, such as the National Institutes of Health.
