When Should You Not Take a Steroid? A Crucial Guide to Safe Medication Use

Over 90% of patients who take corticosteroids for more than 60 days experience adverse effects, underscoring the serious nature of these medications. This makes understanding when you should not take a steroid a vital part of your medication safety plan. This guide outlines the key conditions, drug interactions, and circumstances where steroid use should be avoided or approached with extreme caution.

Quick Summary

Steroids are not suitable for all patients due to risks like weakened immunity and systemic side effects. Absolute contraindications include systemic fungal infections, while relative precautions involve managing conditions like diabetes, hypertension, and osteoporosis.

Key Points

• Systemic Infections: Avoid steroids if you have an active, systemic fungal, viral, or bacterial infection, as they can weaken your immune system and worsen the illness.

• Live Vaccines: Do not receive a live vaccine while taking high-dose steroids, as your body may be unable to respond effectively, increasing infection risk.

• Allergy History: A documented allergic reaction to a specific steroid is an absolute contraindication for that medication.

• Chronic Conditions: Patients with diabetes, hypertension, osteoporosis, or GI issues require careful monitoring and potential dose adjustments, especially with long-term steroid use.

• Injections and Topicals: Local steroid applications are unsafe over infected skin or into already-infected joints, and repeated injections can damage tissue.

• Abrupt Discontinuation: Never stop taking oral steroids suddenly, especially after long-term use. A gradual tapering schedule is necessary to prevent serious adrenal insufficiency.

Absolute Contraindications: When to Avoid Steroids Entirely

Corticosteroids are powerful drugs that can be life-saving, but their use is inappropriate or dangerous in certain situations. Absolute contraindications mean that under no circumstances should a steroid be administered due to an unacceptable risk of harm.

• Systemic Fungal Infections: Corticosteroids weaken the immune system, making it easier for fungal infections to spread throughout the body. Taking a steroid during a systemic fungal infection can worsen the condition and lead to severe, potentially fatal, complications.
• Known Allergic Reaction: If a patient has a documented history of an allergic reaction or hypersensitivity to a specific steroid or any of its components, that medication must be avoided.
• Concurrent Live or Live-Attenuated Vaccines: For patients on immunosuppressive doses of corticosteroids, live vaccines (such as the measles, mumps, and rubella vaccine) can cause the vaccine-related illness because the immune system is too weak to mount a proper defense. Healthcare providers recommend delaying vaccination for at least three months after stopping high-dose steroid therapy.
• Cerebral Malaria: Dexamethasone is specifically contraindicated for use in patients with cerebral malaria, as studies have shown it may worsen patient outcomes.

Relative Contraindications: Use with Caution and Medical Guidance

Certain pre-existing medical conditions and patient factors do not completely prohibit steroid use but require careful evaluation and monitoring by a healthcare provider. The potential benefits must be carefully weighed against the risks.

Existing Infections

While a systemic fungal infection is an absolute contraindication, other active infections (viral, bacterial, or parasitic) require extreme caution. Steroids can mask the signs of infection and suppress the immune response needed to fight it, which can be dangerous. This includes specific viruses like herpes infections of the eye, which can be worsened by steroid use.

Chronic Conditions

For patients with chronic conditions, long-term or high-dose steroid therapy poses significant risks.

• Diabetes: Corticosteroids can elevate blood glucose levels and may trigger or worsen diabetes, especially in patients already at risk. Close monitoring of blood sugar is essential.
• Hypertension and Heart Disease: Steroids can cause fluid retention and increase blood pressure, which is a concern for patients with congestive heart failure, hypertension, or a history of recent heart attacks.
• Osteoporosis: Prolonged steroid use can accelerate bone loss, leading to a higher risk of fractures. Doctors may recommend calcium and vitamin D supplements or other medications to protect bone density.
• Gastrointestinal Issues: The risk of stomach ulcers and bleeding increases significantly when steroids are combined with nonsteroidal anti-inflammatory drugs (NSAIDs). Patients with a history of ulcers or diverticulitis require careful consideration.
• Mental Health Disorders: Steroids can cause mood swings, anxiety, depression, and even psychosis. Patients with a history of mental health problems should be closely watched.

Special Patient Populations

• Pregnancy and Breastfeeding: Steroid use during the first trimester of pregnancy may be linked to certain risks, and high doses can pass into breast milk. A doctor must carefully weigh the risks and benefits.
• Children and Adolescents: Long-term steroid use can slow growth and puberty. Growth should be monitored carefully in young patients receiving these medications.

Drug Interactions

Steroids can interact with numerous other medications, altering their effectiveness or increasing the risk of adverse effects. It is crucial to inform your doctor about all medications, vitamins, and supplements you are taking.

Table: Common Corticosteroid Drug Interactions

Medication Type	Example	Interaction with Steroids	Effect
NSAIDs	Ibuprofen, naproxen	Increases risk of stomach ulcers and bleeding.	Higher risk of gastrointestinal complications.
Diabetes Medications	Insulin, metformin	Can raise blood glucose levels, reducing the effectiveness of diabetes drugs.	May require dosage adjustments for diabetes medications.
Anticoagulants	Warfarin	Can alter the blood-thinning effect, requiring closer monitoring.	Inconsistent blood thinning, potentially increasing bleed risk.
CYP3A4 Inducers	Rifampin, phenytoin	Speeds up the metabolism of steroids, making them less effective.	Reduced steroid efficacy, requiring dose increases.
Live Vaccines	MMR, Varicella	Suppressed immune system can't fight the weakened virus, leading to infection.	Potentially serious vaccine-related illness.

Local Steroid Risks

For treatments like steroid injections or topical creams, risks are often localized but can still be significant.

• Injection Site Infection: Steroid injections into a joint or tissue should not be performed if there is a skin infection at or near the injection site. Injections into already infected joints (septic arthritis) are also strictly contraindicated.
• Weakened Tissue: Repeated injections into the same area can weaken tendons, ligaments, and bone over time.
• Topical Application: Using steroid creams on infected or damaged skin can worsen the condition. Prolonged use can also lead to skin thinning and other dermatological issues.

Alternatives to Corticosteroids

Depending on the condition, alternatives to steroid therapy may be available. These options range from lifestyle adjustments to other medications that may carry fewer risks.

• NSAIDs: Over-the-counter and prescription NSAIDs like ibuprofen and naproxen can manage pain and inflammation for milder conditions.
• Physical Therapy: For musculoskeletal issues, physical therapy can improve function and reduce pain without injections or oral steroids.
• Biologics: For severe autoimmune diseases like rheumatoid arthritis, biologics target specific components of the immune system to reduce inflammation more selectively than systemic steroids.
• Steroid-Sparing Drugs: Other medications, such as methotrexate, can be used to manage chronic inflammatory conditions.
• Supplements and Lifestyle: Dietary changes (e.g., anti-inflammatory diet), supplements (e.g., omega-3 fatty acids, vitamin D), and stress management can help with chronic inflammation.

Conclusion: Consult Your Physician

While corticosteroids offer potent anti-inflammatory and immunosuppressive effects, they are not without significant risks. Understanding when you should not take a steroid is the first step toward safe medication use. Given the complexity of interactions, precautions, and individual health factors, self-treating with steroids is never recommended. Always have a thorough discussion with your doctor about your medical history, current medications, and any potential infections before starting or continuing a steroid regimen. For more information on corticosteroid side effects, you can visit the Hospital for Special Surgery's health library at https://www.hss.edu/health-library/conditions-and-treatments/steroid-side-effects-how-to-reduce-corticosteroid-side-effects.

Frequently Asked Questions

Can I take steroids if I have an infection?

You should generally not take steroids with an active, systemic infection. Since corticosteroids suppress the immune system, they can make it harder for your body to fight the infection and can mask the symptoms, leading to potentially dangerous complications.

What if I have diabetes and need a steroid?

If you have diabetes, steroid use will likely require close monitoring of your blood sugar levels, as corticosteroids can cause hyperglycemia. Your doctor may need to adjust your diabetes medication dosage temporarily while you are on steroids.

Is it safe to get a vaccine while taking steroids?

While on high-dose or immunosuppressive steroids, you should not receive live or live-attenuated vaccines. Your doctor will advise you to delay these vaccinations for several months after stopping the steroid therapy.

Can I just stop taking my oral steroid if I feel better?

No, never stop taking oral steroids suddenly. Long-term use can suppress your body's natural hormone production, and abrupt discontinuation can lead to a dangerous condition called adrenal insufficiency. Always follow your doctor's plan for gradually tapering the dose.

Are there special precautions for steroid creams?

Yes. You should not apply topical steroid creams over infected skin, on your face, or in skin folds unless directed by a doctor. Long-term or excessive use can lead to skin thinning and other local side effects.

What medications should not be taken with a steroid?

Several drugs interact with steroids. You should be cautious with NSAIDs (e.g., ibuprofen) to avoid increased ulcer risk, and inform your doctor about any diabetes medications, anticoagulants (e.g., warfarin), or certain antibiotics you are taking.

Are there risks with steroid injections?

For steroid injections, absolute contraindications include infections at the injection site or in the joint itself. Overly frequent injections can also weaken soft tissues and bone in the area over time.