Do Long-term Low-Dose Steroids Increase Cardiovascular Risk?

Mauricio Wajngarten, MD

December 17, 2021

We prescribe glucocorticoids for many types of patients, especially those with inflammatory diseases. For several conditions, such as polymyalgia rheumatica and inflammatory bowel disease, we keep patients on long-term, low-dose steroid therapy. These drugs can cause fluid retention, decreased glucose tolerance, hypertension, and behavioral and mood changes. Patients can also experience digestive problems, increased appetite, and weight gain.

Adverse effects associated with long-term use include Cushingoid appearance, cataracts, elevated intraocular pressure, osteoporosis, and vertebral compression fractures. We also know that administering high doses of glucocorticoids can increase the risk for cardiovascular disease (CVD); however, until recently, there have been ongoing debates about the increased cardiovascular risk associated with the use of these drugs at low doses.

In light of these issues, a team of researchers in the United Kingdom aimed to quantify glucocorticoid dose-dependent cardiovascular risk in people with immune‑mediated inflammatory diseases in a population-based cohort study.

The researchers analyzed medical records from 389 primary care practices linked to hospital admissions and deaths between 1998 and 2017. They identified 87,794 adults with immune-mediated inflammatory diseases (e.g., giant cell arteritis and/or polymyalgia rheumatica, inflammatory bowel disease, rheumatoid arthritis, systemic lupus erythematosus, and/or vasculitis) and no previous CVD.

After a median follow-up of 5 years, strong associations were seen between the administered dose of glucocorticoids and the risk for CVD, including myocardial infarction, heart failure, atrial fibrillation, and cerebrovascular disease.

After 1 year, the overall absolute risk for CVD doubled for individuals taking less than 5 mg prednisolone per day and was six times higher for users of at least 25 mg daily. Many individuals had known modifiable cardiovascular risk factors, including current smoking (24%), obesity (25%), and hypertension (25%).

The researchers showed that individuals taking steroids have an increased risk for a broad range of fatal and nonfatal CVD, and that this risk increases with the dose of steroids and with the duration of steroid treatment.

Contrary to the previous understanding, the findings show that even low doses of prednisolone (<5 mg) double the underlying risk for CVD in patients with immune-mediated inflammatory diseases.

Patients frequently ask their doctors to prescribe steroids to help manage musculoskeletal pain. The researchers suggest restricting the long-term use of steroids, when possible, even at low doses. They also suggest implementing a personalized CVD risk prevention plan for patients that takes current and previous steroid use into account.

This article originally appeared in the Portuguese edition of Medscape.

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