Authors: Khalid H. Al-Jabr, Lama Saleh Alhumaidan, Abdullrahman A. Alghamdi, Meshari Sanad L. Almutairi, Abdulrahman Abdullah Alsubaihi, Sami M. Alrasheedi, Ahmad Alkhdairi, Ali M Alzweihary, Majed Swailem Alrasheedi, Khaled Ali Mohammed Alrasheedi, Mousa Nasser Alrashdi
Categories: Original Article
Source: Journal of Pharmacy & Bioallied Sciences
Corticosteroids are anti-inflammatory medications that are used to reduce inflammation and inhibit the immune system in a variety of disorders, including allergies, asthma, systemic lupus erythematous, eczema, inflammatory bowel disease, and swollen joints or muscles. The goal of this study was to assess the level of awareness and sources of information about the side effects of corticosteroids among the general population in Saudi Arabia.
This observational cross-sectional study was conducted in Saudi Arabia using an electronic questionnaire. A non-probability convenience sampling technique was used. Statistical Package for the Social Sciences (SPSS) was used for data analysis.
The study included 755 participants from Saudi Arabia (67.3% females and 32.7% males). Around 26.8% reported using corticosteroids, and 73.9% were aware of the side effects of glucocorticoids. Among steroid users (202 participants), the most common conditions were allergies (36.1%), asthma or chronic obstructive pulmonary disease (COPD) (21.8%), and skin diseases (27.7%). The majority of respondents (57.9%) used steroids for less than 2 weeks, and topical application (52.5%) was the most common form. Only 30.7% received information about side effects at the time of prescription. The most reported side effects were truncal obesity, moon face, skin thinning, bruising, and slower wound healing.
This study highlights the importance of promoting awareness and knowledge regarding the side effects of corticosteroids in Saudi Arabia. While overall awareness levels were relatively satisfactory, specific side effects require further attention in educational efforts.
KEYWORDS: Autoimmune disorders, awareness, cardiovascular diseases, corticosteroid side effects, diabetes, glucocorticoid, rheumatology
Corticosteroids are naturally occurring hormones that are secreted from the cortical segment of the adrenal glands in a particular zone called the zona fasciculate. They are secreted in the form of glucocorticoids at levels that are tightly controlled by the negative feedback of the hypothalamic–pituitary–adrenal (HPA) axis, stress, and circadian rhythm. Their peak physiological concentration occurs in the morning, when they act as a “natural cup of coffee” in the sense of helping the body cope with a variety of stressors. This occurs by increasing blood sugar levels (hence the name “glucocorticoid”), which is achieved by the breakdown of muscle proteins and fat cells in a process called gluconeogenesis.[1,2]
Synthetic analogs of corticosteroids are known for their anti-inflammatory properties, and nearly every branch of medicine uses them to treat a variety of illnesses, including rheumatological conditions, such as rheumatoid arthritis and organ transplant patients, and obstructive airway diseases, such as asthma. Unfortunately, they are also known for their many adverse effects, which depend on the dose and duration of use.[3] One of the most common self-reported adverse effects is weight gain and Cushing syndrome, which cause fat redistribution in the upper back, face, and central abdomen.[4,5] In addition, hyperglycemia causes preexisting diabetes to worsen or even potentially develop into new-onset diabetes. They can also result in hypertension and fluid retention, and like weight gain and hyperglycemia, these effects have a negative impact on overall cardiovascular health. Musculoskeletal complaints have also been reported (mainly osteoporosis and fragility fractures).[6,7]
Postoperatively, more complications have been reported in long-term steroid users compared with nonusers, including an increased risk of urinary tract infections and even septic shock,[8] and prolonged hospital stays and slow wound healing.[9] Distinctive adverse outcomes occur in the pediatric age group, which mainly involve growth stunting and pubertal delay.[10] Inhaled steroids, interarticular injections, and topical steroid cream have also been reported to have adverse effects, such as local oral thrush, skin thinning, easy bruising, cartilage damage, and glaucoma, as well as systemic infections and psychosis, although these are much less common.[9,11]
Many clinicians refer to corticosteroids as a “necessary evil” as patients must be willing to put up with a long list of adverse effects to benefit from their therapeutic capabilities. The goal is to balance the benefits versus the harm, as the positive and negative effects are dose dependent. The aim is to administer the lowest dose with the greatest effect for the shortest amount of time possible.[7] In addition, proper stepping down of medication is very important as abrupt discontinuation is associated with shock and adrenal insufficiency syndrome.[5,12] With proper patient education and early recognition of corticosteroids, interventions can be made before any serious adverse effects develop. The aim of this study was to estimate the perceptions of corticosteroid adverse effects in a general population in Saudi Arabia. The factors that influence their perceptions were also examined. The results could be used to raise awareness of corticosteroid usage and help with the assessment of steroid users’ knowledge and the prevalence of commonly known adverse effects.
This quantitative cross-sectional survey examined 755 participants of both genders living in Saudi Arabia, aged 18 years and above. A survey was conducted between May 29, 2023, and July 13, 2023, using an online questionnaire, which was distributed randomly by preassigned data collectors through social media in multiple regions of Saudi Arabia. The questionnaire was tailored to evaluate the knowledge and awareness of corticosteroid side effects by taking into consideration the cultural differences in the Saudi population. It was originally created in English and then appropriately translated into Arabic to represent the broadest community possible. Participants were excluded if they were younger than 18 years old, did not own an electronic device, were illiterate, did not provide full answers, did not provide consent, or were not living in Saudi Arabia.
The study was reviewed by the Committee of Research Ethics, Deanship of Scientific Research, Qassim University, and received approval from the institutional review board (IRB) on May 22, 2023, number 23-39-04.
A questionnaire utilized in this study was well structured in collaboration with a previous study.[3] It has been reviewed and validated by multiple specialists and has three sections. The first part involves demographic characteristics (age, gender, residence, education, and work in the medical field). The second part is related to awareness, and the third part is about patients using corticosteroids.
Descriptive statistics were used to describe and summarize the characteristics of the study participants and their responses. Frequencies and percentages were calculated for categorical variables, such as the participants’ responses to knowledge questions. For continuous variables, the medians and interquartile ranges (IQRs) were calculated.
All statistical calculations were performed using IBM Statistical Package for the Social Sciences (SPSS) version 27.0.1.
A total of 755 participants living in Saudi Arabia satisfied the inclusion criteria and were included in the analysis (67.3% females and 32.7% males). The most common age group was 18–25 years (54.8%), 76.3% had university education and 34.3% worked in the medical field.
Regarding corticosteroid use, 26.8% of participants reported using them. Regarding awareness of glucocorticoid’s side effects, 73.9% of participants indicated having heard about them. The main sources of information about its side effects were social media (48.7%), relatives and friends (48.0%), websites and medical books (44.4%), and doctors (42.3%).
Table 1 presents the questions assessing the knowledge of participants regarding the side effects of steroids, along with the correct responses, scoring, and proportion of correct responses. The majority of participants demonstrated an average level of awareness, with correct response rates ranging from 34.4% to 61.2%. The systemic side effects that participants were most aware of included truncal (central) obesity (61.2%), moon face (61.1%), swelling in the lower legs (55.2%), and rounding of the upper back (54.4%).
Steroid users (N = 202). The majority of participants using steroids had various conditions, including allergies (36.1%), asthma or chronic obstructive pulmonary disease (COPD) (21.8%), and skin conditions, such as eczema (27.7%). A significant proportion (57.9%) reported using steroids for less than 2 weeks, while 22.8% used them for more than 2 months. Regarding the form of corticosteroid used, topical application was the most common (52.5%), followed by inhalers (24.8%) and oral tablets (16.8%).
When asked whether they received information about the side effects of corticosteroids when first prescribed, 30.7% responded affirmatively, while 69.3% did not receive such information. Among those who received information (N = 62), the majority received verbal instructions (64.5%), while a smaller proportion received written information (35.5%). Additionally, a considerable number of steroid users (44.1%) also reported using vitamin D supplementation, while others used calcium supplements (12.4%) and proton-pump inhibitors (12.4%) [Table 2].
Table 3 shows the rates of steroid users (N = 202) who reported experiencing various side effects. Among systemic side effects, the most commonly reported were truncal (central) obesity (23.8%), moon face (22.8%), and skin thinning (24.3%). Skin-related side effects, such as bruising (17.3%) and slower wound healing (14.4%), were also observed. In terms of vascular and skeletal system effects, hypertension (15.3%) and an increased risk of bone fracture (13.9%) were reported by some participants. Side effects related to the nervous system and glands included mood changes (25.2%) and hyperglycemia (15.3%).
Among topical side effects, loss of skin color (32.2%) and itching (31.7%) were the most commonly reported. Additionally, a proportion of participants reported experiencing inhaler-related side effects, such as fungal infection in the mouth (10.9%) and abnormal voice changes (12.9%).
The median awareness score, which represents the level of awareness of steroids’ side effects, was 11 out of a total possible score of 24 (median (IQR): females = 11 (7–16) and males = 11 (5–17)). An insignificant difference in awareness was found based on gender (P = 0.300) or education level (P = 0.060). However, age showed a significant association with awareness (P = 0.022), with the age group of 36–45 years having the highest median awareness score of 12 (median (IQR): 18–25 years = 11 (6–15), 26–35 years = 11 (7–20), 36–45 years = 12 (6–21), 46–55 years = 9 (4–14), and above 55 years = 9 (6–14)). Work in the medical field was strongly associated with higher awareness scores (P < 0.001) compared with those not working in the medical field (median (IQR): non-healthcare workers = 9 (5–13) and healthcare workers = 16 (10–23)).
Regarding the sources of information, obtaining information from doctors (P < 0.001) and websites and medical books (P < 0.001) was significantly associated with higher awareness scores. Obtaining information from relatives and friends (P < 0.001) was significantly associated with lower awareness (median (IQR): doctor = 15 (10–23), relatives and friends = 11 (7–16), and websites and medical books = 16 (11–22)). An insignificant association was found between awareness and the use of corticosteroids (P = 0.339) (median (IQR): nonusers = 11 (6–17) and users = 11 (6–15)) [Table 4].
The results provide valuable insights into the demographic characteristics of the participants, their level of awareness regarding different side effects, the prevalence of side effects among steroid users, and factors that may influence awareness levels. These findings have implications for healthcare professionals involved in prescribing corticosteroids and educating patients about their potential side effects.
The study revealed that a significant proportion of participants (26.8%) reported using corticosteroids. This finding highlights the widespread use of corticosteroids among the population and the importance of ensuring adequate awareness and knowledge of their potential side effects. It is noteworthy that 34.3% of the participants were medical professionals or students, indicating that individuals in the medical field were well represented in the sample. This may have contributed to a higher level of awareness among this subgroup, as demonstrated by their significantly higher awareness scores compared with nonmedical professionals.
We investigated the knowledge of participants with a focus on systemic, topical, and inhaler side effects of corticosteroids. The results indicated that the majority of participants demonstrated an average level of awareness regarding these side effects, with varying proportions of correct responses ranging from 34.4% to 61.2%. When examining the systemic side effects, participants showed relatively high levels of awareness of certain side effects. Truncal (central) obesity and moon face were the most well-known systemic side effects, with correct response rates of 61.2% and 61.1%, respectively. This suggests that participants were aware of the physical changes associated with corticosteroid use. Furthermore, a significant proportion of participants demonstrated awareness of swelling in the lower legs (55.2%) and rounding of the upper back (54.4%), indicating a reasonable understanding of these side effects. Irmak Sayın et al. assessed the knowledge of corticosteroids’ side effects and found that truncal obesity and moon face were well known.[13]
Regarding topical side effects, participants exhibited good awareness of thinning or depression of the skin (55.6%) and loss of skin color (53.1%). These findings imply that participants had a solid grasp of the dermatological effects associated with corticosteroid use. However, awareness levels for other topical side effects were not as high, indicating a potential gap in knowledge. Coondoo et al. focused on the awareness of topical side effects among dermatology patients, and their findings aligned with our study, demonstrating good awareness of thinning or depression of the skin and loss of skin color.[14]
In terms of inhaler side effects, participants demonstrated the highest level of awareness for fungal infection of the mouth, with a correct response rate of 44.0%. This suggests that participants had a reasonable understanding of the potential oral complications associated with corticosteroid inhalers. However, it is important to acknowledge that awareness levels for other inhaler side effects were relatively low, indicating a need for improved education and awareness. A significant number of participants reported using steroids for various conditions, including allergies, asthma or COPD, and skin conditions, such as eczema, which are consistent with previous studies.[15,16]
The majority of participants reported using steroids for less than 2 weeks, while a smaller proportion used them for more than 2 months. This finding is consistent with the short-term nature of corticosteroid therapy for many acute conditions, such as allergic reactions or exacerbations of respiratory diseases.[17,18] However, it is important to note that a significant proportion of participants used steroids for an extended period, which may indicate chronic or recurrent conditions that require longer-term treatment. Regarding the form of corticosteroid used, topical application was the most common, followed by inhalers and oral tablets. Topical corticosteroids are commonly prescribed for skin diseases, inhaled corticosteroids are prescribed for respiratory conditions, and oral corticosteroids are prescribed for a variety of systemic inflammatory disorders.[19]
One important aspect that our study highlights is the lack of information about the side effects of corticosteroids provided to the majority of participants at the time of their prescription. This finding is concerning and suggests a potential gap in patient education. It is important for healthcare professionals to communicate the potential risks and side effects associated with corticosteroid use to ensure that patients are well informed and can make informed decisions about their treatment. Several studies have emphasized the importance of providing comprehensive information about corticosteroid therapy, including its benefits and potential adverse effects.[20] Further research is needed to explore the reasons behind the inadequate provision of information and to develop strategies for improving patient education in this context.
In addition to corticosteroids, a notable proportion of steroid users reported using vitamin D supplements, calcium supplements, and proton-pump inhibitors. These findings suggest that individuals using steroids may be utilizing adjunctive therapies to manage potential side effects or address specific needs associated with their underlying conditions. However, further investigation is necessary to understand the specific rationale and efficacy of these concurrent therapies in relation to corticosteroid use.
Systemic side effects were among the most commonly reported in our study. Truncal (central) obesity, moon face, and skin thinning were reported by a significant proportion of participants. These results are consistent with the literature that documented the association between systemic corticosteroid use and changes in body composition, including increased fat deposition, and alterations in fat distribution.[21,22]
Skin-related side effects were also observed in our study, with bruising and slower wound healing in a notable proportion of participants. These findings are supported by previous research that highlighted the potential impact of corticosteroid use on skin integrity and wound healing.[23] Vascular and skeletal system effects were evident. Hypertension and increased risk of bone fracture were reported by some participants, which were congruent with the studies that report the adverse effects of steroid on blood pressure regulation and bone health.[24] The nervous system and glands were also affected by steroid use, as indicated by the reports of mood changes and hyperglycemia among the participants.[25]
Regarding topical side effects, loss of skin color and itching were the most commonly reported in our study, which are in line with prior research that has highlighted the dermatological side effects of topical corticosteroid use.[26] Inhaler-related side effects were also observed among participants, with fungal infection in the mouth and abnormal voice changes, which are in agreement with previous studies.[27]
The results of this study provide valuable insights into the awareness and knowledge of corticosteroids’ side effects. However, certain limitations should be considered. First, the study relied on self-reported data, which may be subject to recall and response biases. Second, the study sample was limited to individuals in Saudi Arabia, so the findings may not be generalizable. Future research could include larger and diverse samples to further explore the factors influencing awareness levels and knowledge of corticosteroid side effects.
In conclusion, this study highlights the importance of promoting awareness and knowledge regarding corticosteroid side effects among individuals in Saudi Arabia. While overall awareness levels were relatively satisfactory, specific side effects require further attention in educational efforts. Age, work in the medical field, and specific sources of information were found to be significant factors influencing awareness levels.
Nil.
There are no conflicts of interest.