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- Presentation
Systemic Steroids: GI Ulcer Prevention, Endocrine Risks, and Lipid Management
Description
The talk reviewed systemic steroid management with emphasis on GI, endocrine, and lipid issues. For GI protection, it noted that steroids alone do not clearly increase peptic ulcer risk, so routine PPI prophylaxis is usually unnecessary unless patients also use NSAIDs/aspirin or have other ulcer risk factors such as prior ulcers, smoking, alcohol use, older age, antiplatelet/anticoagulant use, or severe illness; H2 blockers may be preferable in some cases because of fewer long-term adverse effects. Endocrine risks included steroid-induced diabetes, adrenal suppression, and Cushingoid effects: baseline A1c and early glucose monitoring were recommended, especially in higher-risk patients, and adrenal suppression becomes likely with prednisone doses above 20 mg daily for at least three weeks or with Cushing features. Long-term steroid users may need slow tapers, morning cortisol checks, stress-dose coverage during illness or surgery, and education to carry medical identification for up to a year after stopping steroids. The lipid section stressed that LDL, not HDL, is the main target, with lower LDL goals for primary and secondary prevention and even more aggressive targets in high-risk patients, especially those with autoimmune diseases like lupus and psoriasis that carry increased ASCVD risk. Risk calculators, coronary artery calcium scoring, statins, and newer agents such as PCSK9 inhibitors can help achieve tighter control, and patients with elevated LDL should be appropriately evaluated and treated.
View moreConclusions
- Systemic glucocorticoids alone do not appear to substantially increase peptic ulcer risk, so routine PPI prophylaxis is usually unnecessary unless additional risk factors are present, especially NSAID or aspirin use.
- Patients on steroids should be screened for diabetes and monitored for hyperglycemia early after initiation, with baseline A1C and ongoing glucose checks.
- Adrenal suppression becomes a significant concern with prolonged or higher-dose steroid use, so tapering should be slow and guided by morning cortisol testing when doses get low.
- People recovering from long-term steroid use may need stress-dose coverage for up to a year after stopping steroids and should be warned to carry identification.
- Steroid withdrawal symptoms can mimic adrenal insufficiency but may occur despite normal cortisol, and they are often managed by slowing the taper or temporarily increasing the dose.
- Cardiovascular risk management should be more aggressive than older practice suggested, because LDL targets are now lower and lower LDL is considered better and safe.
- High HDL should not reassure clinicians when LDL is elevated, since LDL and ApoB are the more important treatment targets.
- Patients with autoimmune inflammatory diseases such as lupus and dermatomyositis have increased ASCVD risk and may need treatment intensity similar to other high-risk populations.
- Coronary artery calcium scoring and specialized preventive cardiology referral can help identify patients who need more aggressive lipid-lowering therapy.
- Newer lipid-lowering agents such as ezetimibe and PCSK9 inhibitors expand treatment options when statins alone are not enough or are not accepted.
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