# Corticosteroid Therapy and Adverse Effects > Corticosteroid therapy for NEET-PG Medicine: dose equivalents, HPA axis suppression, tapering schedules, stress dosing and commonly tested adverse effects. - Canonical URL: https://prepelephant.com/topics/neet-pg/medicine/corticosteroid-therapy-adverse-effects - Exam / course: NEET-PG · Subject: Medicine - Publisher: PrepElephant (https://prepelephant.com) — Prepared and reviewed by the PrepElephant Academic Review Team - First published: 2026-10-08 - Last updated: 2026-10-08 - Reference basis: Katzung's Basic and Clinical Pharmacology; Williams Textbook of Endocrinology; Harrison's Principles of Internal Medicine - How to cite: "Corticosteroid Therapy and Adverse Effects", PrepElephant, https://prepelephant.com/topics/neet-pg/medicine/corticosteroid-therapy-adverse-effects ## Direct answer Corticosteroid therapy causes adverse effects that depend mainly on dose and duration, and HPA axis suppression is the one most important to remember. Prednisolone 5 mg is roughly equivalent to hydrocortisone 20 mg and dexamethasone 0.75 mg for glucocorticoid activity, although mineralocorticoid effects differ between agents. Courses of supraphysiological steroid lasting around three weeks or more can suppress the axis, so tapering and stress-dose cover are needed when steroids stop or when illness and surgery intervene. ## What you must remember - **Equivalence:** Hydrocortisone 20 mg, prednisolone 5 mg, methylprednisolone 4 mg and dexamethasone 0.75 mg are roughly equivalent in glucocorticoid potency. - **Mineralocorticoid effect:** Hydrocortisone and prednisolone retain sodium-retaining activity, whereas dexamethasone has almost none. - **HPA suppression:** Exogenous steroid suppresses hypothalamic CRH and pituitary ACTH, leading to adrenal atrophy that can persist for months after a prolonged course. - **Common effects:** Hyperglycaemia, central obesity, hypertension, cushingoid features, proximal myopathy, cataract, glaucoma and peptic ulceration. - **Infection risk:** Pneumocystis pneumonia, tuberculosis reactivation and Strongyloides hyperinfection; screen before prolonged high-dose therapy in endemic areas. - **Bone effects:** Osteoporosis and avascular necrosis of the femoral head; calcium and vitamin D are given, with antiresorptive therapy for higher-risk patients. - **Tapering and stress dosing:** Taper gradually after prolonged courses, and give stress-dose hydrocortisone during major illness or surgery in suppressed patients. ## Tapering a patient through a five-week course A 46-year-old woman with a flare of rheumatoid arthritis has taken prednisolone 30 mg daily for five weeks. Her glucose is raised, her blood pressure is 150/92 mmHg, and she has noticed weight gain and a rounder face. 1. **Recognise the risk:** A course of this length carries a real risk of axis suppression, so the taper is planned from the start. 2. **Taper in steps:** The dose falls in steps, typically a few milligrams every one to two weeks while above physiological levels, slowing as it approaches about 5 mg daily. 3. **Let the disease set the pace:** Each step is guided by disease activity, since the flare returns if the taper is too fast. 4. **Test the axis:** A morning cortisol measurement, interpreted with the clinical picture and sometimes a short synacthen stimulation test, decides whether replacement or stress-dose cover continues. 5. **Manage adverse effects:** Glucose monitoring, calcium and vitamin D for bone protection, blood pressure review and an eye check run alongside the taper. 6. **Cover surgery:** If she needs surgery during the taper, stress-dose hydrocortisone is given at induction rather than relying on the reduced prednisolone. The lesson is that the taper is planned with the disease, not just with the drug. ## Where the exam tries to catch you Corticosteroid vignettes rest on a few confusions that the examiner returns to. - **Trap:** assuming a cushingoid patient with low ACTH has an endogenous tumour — **Correct:** exogenous steroid suppresses ACTH, so ACTH is low in iatrogenic Cushing syndrome but raised or inappropriately normal in pituitary-dependent Cushing disease. - **Trap:** treating drug equivalence as clinical equivalence — **Correct:** hydrocortisone and dexamethasone are not interchangeable in every setting, because mineralocorticoid action and duration differ. - **Trap:** calling steroid withdrawal arthralgia, myalgia and fatigue adrenal insufficiency without testing — **Correct:** withdrawal syndrome is not always adrenal insufficiency, and a morning cortisol result helps settle the question. - **Trap:** prescribing prolonged high-dose steroids without thinking about infection — **Correct:** in India, tuberculosis and Strongyloides are the infections to screen for first. ## Frequently asked questions ### What are the equivalent doses of prednisolone and hydrocortisone? Prednisolone 5 mg is approximately equivalent to hydrocortisone 20 mg in glucocorticoid activity, a conversion that matters when switching between oral and intravenous regimens. Dexamethasone 0.75 mg is comparable to prednisolone 5 mg but has almost no mineralocorticoid effect. ### Why does exogenous corticosteroid lower ACTH levels? Exogenous glucocorticoids suppress hypothalamic CRH and pituitary ACTH through negative feedback, causing adrenal atrophy and low ACTH. This pattern distinguishes steroid-induced cushingoid features from ACTH-dependent Cushing syndrome, where ACTH is raised or inappropriately normal. ### How long must steroids be taken before adrenal suppression is a concern? Adrenal suppression becomes a concern after supraphysiological corticosteroid courses lasting around three weeks or longer, with risk rising with dose and duration. Patients should receive sick-day advice and stress-dose cover during illness or surgery until the axis is formally assessed. ### Which infections are screened before prolonged high-dose steroids? Tuberculosis and Strongyloides stercoralis are screened before prolonged high-dose corticosteroid therapy, especially in India where both are common, to prevent reactivation or hyperinfection. Prophylaxis against Pneumocystis may be considered for selected patients on high-dose steroids with other immunosuppressants. ### What is the stress-dose cover for major surgery in a steroid-dependent patient? Major surgery in a steroid-dependent patient is covered with hydrocortisone 100 mg at induction, followed by 200 mg over 24 hours, then tapered as recovery allows. Complex or prolonged cases should be planned with an endocrinologist, since dosing depends on the surgery and the patient.