Steroids Explained: Benefits, Risks and How They Are Used Safely in Rheumatology
Steroids (more accurately called corticosteroids) are among the most powerful and effective anti-inflammatory medications used in medicine. In rheumatology, they can dramatically reduce pain, stiffness and swelling, often within hours or days.
At the same time, steroids are also one of the most misunderstood and feared treatments. Many patients worry about side effects, long-term harm, or becoming “dependent” on them.
The reality is more nuanced. Steroids are neither good nor bad in themselves — they are powerful tools. When used carefully and for the right reasons, they can be life-changing and sometimes life-saving. Problems arise when they are used for too long, at too high a dose, or without a long-term treatment plan.
What Are Steroids?
Steroids used in rheumatology are corticosteroids, such as:
prednisolone
prednisone
methylprednisolone
hydrocortisone
dexamethasone
They are completely different from anabolic steroids used for bodybuilding.
Corticosteroids mimic the effects of cortisol, a natural hormone produced by the adrenal glands. Cortisol plays a key role in regulating:
inflammation
immune responses
blood pressure
metabolism
the body’s response to stress and illness
How Do Steroids Work?
Steroids suppress inflammation by:
inhibiting inflammatory cytokines
reducing immune cell activation
stabilising blood vessels
reducing tissue swelling
This broad anti-inflammatory effect explains why steroids:
act quickly
work across many different inflammatory diseases
relieve symptoms far faster than most other treatments
Why Are Steroids Used in Rheumatology?
Steroids are used for several important reasons.
1) Rapid Symptom Control
Steroids can provide fast relief when:
joints are severely inflamed
pain and stiffness are disabling
sleep and daily function are severely affected
This rapid improvement can be life-changing while longer-acting treatments take effect.
2) Bridging Therapy
Steroids are often used as a temporary bridge while slower medications begin to work.
For example:
DMARDs such as methotrexate
biologics
targeted synthetic DMARDs
These drugs may take weeks or months to become effective. Steroids help control inflammation during this period.
(Related reading: DMARDs Explained: Methotrexate, Sulfasalazine, Hydroxychloroquine, Mycophenolate and Leflunomide)
(Related reading: Anti-TNF Treatments in Rheumatology – What Patients Should Know)
3) Treatment of Flares
Steroids are often used to treat disease flares in:
rheumatoid arthritis
psoriatic arthritis
lupus
vasculitis
They allow inflammation to be brought under control quickly.
(Related reading: Rheumatoid Arthritis Explained: Symptoms, Diagnosis and Treatment)
(Related reading: Psoriatic Arthritis Explained)
4) Emergency and Organ-Threatening Disease
In some situations, steroids are life-saving.
Examples include:
giant cell arteritis (to prevent blindness)
lupus nephritis
severe vasculitis
severe inflammatory lung disease
In these cases, high-dose steroids are used urgently to prevent permanent damage.
Short-Term vs Long-Term Steroid Use
This distinction is crucial.
Short-Term Use
Short courses of steroids (days to weeks) are usually very safe.
They are commonly used for:
acute flares
bridging therapy
short-term symptom control
Most people tolerate short courses extremely well.
Long-Term Use
Long-term steroid use (months to years) is where most risks arise.
Problems include:
cumulative side effects
adrenal suppression
dependency
increased cardiovascular and metabolic risk
For this reason, modern rheumatology aims to:
Use steroids at the lowest effective dose, for the shortest possible time, with a clear exit strategy.
Common Side Effects
Most people experience either no side effects or only mild, temporary ones — especially with short courses.
Common effects include:
increased appetite
weight gain
fluid retention
facial puffiness (“moon face”)
indigestion
insomnia
mood changes
anxiety or irritability
These effects are usually:
dose-related
reversible
improve as the dose is reduced
Are Steroid Side Effects Reversible?
This is one of the most common and important patient concerns.
The reassuring answer is: most common steroid side effects are reversible.
Weight Gain and Increased Appetite
Steroids often increase appetite and cause fluid retention.
weight gain is usually dose-related
appetite normalises as the dose is reduced
fluid retention settles as steroids are tapered
most people gradually lose steroid-related weight once steroids are stopped
‘Moon Face’ and Facial Puffiness
Facial rounding (“moon face”) is caused by:
fat redistribution
fluid retention
This is:
dose-dependent
usually reversible
gradually improves as steroids are reduced or stopped
For most patients, facial appearance returns to normal over weeks to months after steroid withdrawal.
Skin Changes and Bruising
Steroids can cause:
skin thinning
easy bruising
acne
These changes usually:
improve with dose reduction
gradually reverse after stopping steroids
Mood and Sleep Disturbance
Steroids can cause:
anxiety
low mood
irritability
insomnia
These effects are:
more common at higher doses
usually reversible
improve as the dose is lowered
Gastrointestinal Side Effects and Stomach Protection
Steroids can irritate the stomach lining and increase the risk of:
indigestion
gastritis
stomach ulcers
gastrointestinal bleeding
This risk is higher when steroids are combined with:
NSAIDs (such as ibuprofen or naproxen)
aspirin
Blood thinners such as warfarin or 'DOACs (direct oral anticoagulants e.g. apixaban)
Use of PPIs for Gastric Protection
Many patients taking medium- or long-term steroids are prescribed a proton pump inhibitor (PPI), such as:
omeprazole
lansoprazole
These medications:
reduce stomach acid
protect the stomach lining
reduce ulcer and bleeding risk
PPIs are particularly important in patients who:
are older
have a history of ulcers
take NSAIDs
Taking blood thinners such as warfarin or DOACs
take higher steroid doses
Long-Term Risks of Steroids
With prolonged or high-dose steroid use, more serious complications may develop.
These include:
osteoporosis and fractures
diabetes
high blood pressure
increased infection risk
cataracts and glaucoma
muscle wasting
skin thinning and bruising
delayed wound healing
This is why long-term steroid use requires:
careful monitoring
bone protection
regular review of dose and necessity
Bone Protection During Steroid Treatment
Steroids accelerate bone loss and increase fracture risk.
Anyone taking long-term steroids should have:
assessment of fracture risk
calcium and vitamin D supplementation
consideration of bone-protective medication
Calcium and Vitamin D
Most patients on long-term steroids are advised to take:
calcium supplements (if dietary calcium intake inadequate)
vitamin D supplements
These help support bone health but are not sufficient on their own to prevent steroid-induced osteoporosis.
Bisphosphonates and Other Bone-Protective Drugs
Many patients also require bone-protective medication, such as:
alendronic acid
risedronate
zoledronic acid
These drugs:
reduce bone loss
reduce fracture risk
(Related reading: DEXA Scans Explained: What They Measure and How They Are Used)
(Related reading: Understanding bone health and osteoporosis)
Why Steroids Must Be Tapered Slowly
The adrenal glands naturally produce cortisol.
When someone takes steroids for more than a few weeks:
the adrenal glands reduce their own cortisol production
the body becomes dependent on external steroids
If steroids are stopped suddenly, this can cause:
adrenal crisis
severe fatigue
low blood pressure
nausea
collapse
For this reason, steroids must always be reduced gradually under medical supervision.
Steroid-Sparing Strategies
Steroids should not be the long-term solution for inflammatory disease.
Modern rheumatology focuses on replacing steroids with:
DMARDs
biologics
targeted synthetic DMARDs
These treatments control inflammation more safely over the long term.
(Related reading: DMARDs Explained)
(Related reading: Anti-TNF Treatments in Rheumatology)
Steroid Injections into Joints
Steroids can also be injected directly into inflamed joints.
These injections:
deliver high local anti-inflammatory effect
minimise whole-body exposure
can relieve pain for weeks or months
They are particularly useful for:
isolated joint flares
bursitis
tendon sheath inflammation
However, repeated frequent injections into the same joint are avoided because of potential cartilage damage.
Sick-Day Rules for Patients Taking Steroids
This is one of the most important — and often overlooked — aspects of safe steroid use.
People taking long-term steroids may not be able to produce enough natural cortisol during physical stress.
This matters during:
infections
surgery
severe illness
vomiting or diarrhoea
General Sick-Day Rules
If you are taking long-term steroids:
Do not stop steroids suddenly.
If you develop a significant illness or infection, your steroid dose may need to be temporarily increased.
If you are vomiting and cannot keep tablets down, urgent medical advice is required.
If you are admitted to hospital or have surgery, doctors must be told that you are taking steroids.
Many patients are advised to:
carry a steroid card
wear a medical alert bracelet
When to Seek Urgent Medical Advice
Seek urgent help if you:
have persistent vomiting or diarrhoea
develop a severe infection
feel extremely weak or dizzy
collapse or faint
This ensures emergency staff know that stress-dose steroids may be required.
Are Steroids Safe?
Yes — when used correctly.
Steroids are:
highly effective
often essential
sometimes life-saving
Problems arise from:
prolonged use
unnecessary high doses
lack of monitoring
absence of a steroid-sparing plan
In Summary
Steroids are powerful anti-inflammatory drugs
They work quickly and effectively
Short courses are usually very safe
Long-term use carries significant risks
Most common side effects are reversible
Weight gain and moon face usually improve after stopping steroids
GI protection and bone protection are essential
Steroids must be tapered slowly
Sick-day rules are crucial for safety
Modern rheumatology aims to minimise long-term steroid use
Steroids remain one of the most important tools in rheumatology, but their safe use depends on careful dosing, structured tapering and a clear long-term treatment strategy
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Please note, these posts are for general information only and do not constitute medical advice. Dr Singh would encourage you to speak to your healthcare professional to be assessed and managed for your specific symptoms.