Long-term corticosteroid use caused Cushing’s in 5 patients: Report
Case series highlights dangers of stopping medication suddenly
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Long-term use of corticosteroids may cause iatrogenic Cushing’s syndrome, a side effect of the medication that can lead to noticeable changes such as a rounded, “moon-shaped” face, according to a case report from India.
In the report describing five patients, all but one recovered fully without complications after their daily corticosteroid dose was gradually reduced. The remaining patient died after their medication was stopped abruptly.
Because stopping these medications suddenly can be dangerous, researchers note that corticosteroids should always be gradually tapered.
“Vigilant clinical monitoring, [individualized] tapering plans, judicious prescribing at the lowest effective dose, and the active involvement of clinical pharmacists in adverse-effect surveillance are recommended,” researchers wrote.
The report, “Iatrogenic Cushing’s Syndrome and Fatal Adrenal Crisis Following Systemic Corticosteroid Therapy: A Case Series of Five Patients,” was published in the journal Cureus.
One patient died after corticosteroids were stopped abruptly
Corticosteroids are medications that reduce inflammation by mimicking cortisol, a hormone produced naturally by the adrenal glands. Taking corticosteroids for a long time or at high doses can cause iatrogenic Cushing’s syndrome, meaning medication-induced Cushing’s. Just like endogenous Cushing’s syndrome, where the body produces too much of its own cortisol, most commonly due to Cushing’s disease, taking excess corticosteroid medication can lead to identical symptoms like weight gain and fat buildup.
This report describes one boy, age 12, and four men aged 32 to 65 who developed iatrogenic Cushing’s syndrome after taking corticosteroids for about two months up to about three years. All patients developed a “moon” face, which is caused by an unusual buildup of fat in the face. Some also had purple stretch marks, thin and fragile skin, or darker skin on the abdomen.
Doctors diagnosed Cushing’s syndrome after reviewing each patient’s history of long-term use of corticosteroids along with their physical signs. In some patients, blood tests showed low or low-normal cortisol in the morning. Low cortisol in patients taking corticosteroids suggests that the body’s natural production of cortisol has been reduced because the corticosteroids have replaced it.
The first patient was a 32-year-old man with type 2 diabetes who had received daily injections of dexamethasone, a corticosteroid, for about two months to treat a widespread skin rash. He developed weakness, vomiting, itchy skin, a “moon” face, and skin thinning and redness. His low-normal cortisol level suggested that his adrenal glands were no longer working normally.
His skin rash was later found to be a fungal infection that had been masked by the immunosuppressing effect of dexamethasone. Because the corticosteroid was stopped abruptly, he developed an adrenal crisis within two days. An adrenal crisis follows a sudden reduction in cortisol, causing the body to enter shock. Despite treatment for the fungal infection and supportive care, the man did not survive.
Four patients recovered fully
The second patient was a 60-year-old man with asthma who had taken low-dose dexamethasone tablets for about three years. He developed a “moon” face and a swollen abdomen. He also had liver disease and a fungal infection. Instead of stopping dexamethasone abruptly, doctors slowly switched him to lower-dose prednisolone on alternate days. This gave the adrenal glands time to recover, and he was discharged.
The 12-year-old boy had epileptic encephalopathy, a brain disease that causes seizures and developmental delays. He had taken high-dose oral prednisolone for about five months and developed a “moon” face and purple stretch marks. He also had a lung infection. His cortisol was low-normal, so doctors replaced prednisolone with hydrocortisone, which best matches the body’s cortisol. He made a full recovery.
Several adverse outcomes may have been preventable through rational prescribing at the lowest effective dose and shortest necessary duration, periodic clinical monitoring for Cushingoid features, structured tapering plans aligned with current guideline recommendations, and patient and caregiver education regarding the risks of self-discontinuation.
The fourth patient was a 65-year-old man with rheumatoid arthritis, an autoimmune disease in which the immune system attacks the joints. He had taken oral methylprednisolone daily for eight months and developed a “moon” face and high levels of sugar in the blood. His cortisol was very low. He improved after he was started on a replacement hydrocortisone schedule at doses similar to those normally produced by the adrenal glands.
The fifth patient was a 50-year-old man with osteoarthritis, caused by mechanical wear and tear on the joints, who had taken high doses of prednisolone for about two years. He developed a “moon” face along with bronchopneumonia, a lung infection. Doctors then gradually reduced his prednisolone over several weeks while providing hydrocortisone to meet his body’s needs. This careful taper helped prevent an adrenal crisis, and he recovered fully.
Overall, four of the patients recovered fully because their corticosteroids were gradually reduced or replaced with hydrocortisone as their adrenal glands recovered. The patient who died had his corticosteroids stopped abruptly without replacement, leading to an adrenal crisis.
“Several adverse outcomes may have been preventable through rational prescribing at the lowest effective dose and shortest necessary duration, periodic clinical monitoring for Cushingoid features, structured tapering plans aligned with current guideline recommendations, and patient and caregiver education regarding the risks of self-discontinuation,” the researchers wrote.
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