Logan Steele
Prolonged use of steroids is associated with muscle weakness, a condition known as steroid-induced myopathy. This condition is characterised by progressive muscle weakness, predominantly in the arms, legs, and pelvis, which affects the ability to perform basic activities. While the exact incidence of steroid myopathy is unknown, it is believed to be caused by an excess of endogenous or exogenous corticosteroids, which can arise from steroid treatments for conditions such as asthma, chronic obstructive pulmonary disease, and rheumatoid arthritis. Treatment for steroid-induced myopathy involves reducing or discontinuing steroid use, along with physical therapy and exercises to improve muscle strength.
| Characteristics | Values |
|---|---|
| Prevalence | Corticosteroid-induced myopathy is a highly prevalent adverse effect of prolonged oral or intravenous glucocorticoid use. |
| Symptoms | Muscle weakness, atrophy, and pain, particularly in the arms, legs, and pelvis. |
| Risk Factors | Age, gender (male), obesity, and high doses of steroids, especially multiple doses per day. |
| Treatment | Reducing or stopping steroids is the most effective treatment. Physical therapy, including resistance and aerobic exercises, can also help prevent and treat steroid-induced myopathy. |
| Prognosis | Muscle weakness typically improves within 3 to 4 weeks of tapering steroids, but full recovery can take months to a year. |
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Proximal muscle weakness
Proximal myopathy is a disease that affects the muscles, causing weakness, fatigue, or stiffness. It commonly involves the muscles of the upper and lower limbs, and less commonly the muscles of the neck, face, distal limb, eye, pharynx, respiratory system, and heart. Patients with proximal myopathy experience a generalized feeling of tiredness and/or fatigability, along with muscle pain that disrupts their everyday lives.
Proximal myopathy can be caused by long-term use of statins, corticosteroids, alcohol, SGLT2 inhibitors, COVID-19 vaccination, and antimalarials. It can also be caused by endocrine and metabolic disorders, such as adrenal dysfunction, parathyroid and thyroid disorders, and pituitary gland disorders. In addition, inflammatory myopathies, such as polymyositis, dermatomyositis, inclusion body myositis (IBM), and Systemic Lupus Erythematosus (SLE), are associated with moderate to severe muscle weakness. IBM is the most prevalent acquired myopathy above the age of 50.
Corticosteroid-induced myopathy is a type of proximal myopathy that occurs as an adverse effect of prolonged oral or intravenous glucocorticoid use. It typically affects the pelvic girdle muscles and is associated with muscle weakness and atrophy without pain. The exact incidence of corticosteroid-induced myopathy is unknown, but it is believed to be caused by an excess of endogenous or exogenous corticosteroids. Cushing syndrome is a complication of chronic corticosteroid use, characterized by stigmata such as moon facies and fat redistribution.
The diagnosis of proximal myopathy requires a comprehensive approach, including a thorough history, physical examination, and neurodiagnostic studies. It is important to distinguish proximal myopathy from other conditions that present with weakness, especially in cases with cardiac, respiratory, or pharyngeal muscle involvement. Treatment options for corticosteroid-induced myopathy include steroid withdrawal, switching to nonfluorinated glucocorticoids, alternate-day dosing, and physical therapy.
In summary, proximal myopathy is a muscle disease characterized by weakness, fatigue, and stiffness, commonly affecting the upper and lower limbs. It can be caused by long-term use of certain medications, endocrine and metabolic disorders, and inflammatory myopathies. Corticosteroid-induced myopathy is a type of proximal myopathy that occurs due to prolonged glucocorticoid use and can lead to Cushing syndrome. Diagnosis and treatment of proximal myopathy require a comprehensive approach, including distinguishing it from other conditions with similar presentations.
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Myopathy causes
Myopathies are a group of diseases that cause muscle weakness due to dysfunctional muscle fibres. The condition can be either inherited or acquired.
Inherited myopathies
Inherited myopathies are passed down from immediate family members and are caused by genes. They cause muscle weakness from birth, and symptoms may worsen with age or lead to other complications such as respiratory distress and cardiac issues. Mitochondrial myopathies, for example, are caused by genetic abnormalities in the mitochondria.
Acquired myopathies
Acquired myopathies can develop at any time during a person's life and are caused by a variety of factors that affect the muscles' ability to function properly. Common causes include infections, inflammatory/autoimmune myopathy, and certain drugs.
Inflammatory/autoimmune myopathy
Inflammatory/autoimmune myopathy occurs when the body starts to attack muscle tissue and/or impede muscle function. This can be caused by autoimmune conditions such as sarcoidosis, lupus, and rheumatoid arthritis. Certain drugs, such as steroids, can also cause inflammatory myopathy.
Drug-induced myopathy
Drugs that are used to control elevated blood cholesterol, for example, can cause myopathy. Steroid-induced myopathy is a highly prevalent toxic non-inflammatory myopathy that occurs as an adverse effect of prolonged oral or intravenous glucocorticoid use. An excess of endogenous corticosteroids can be caused by adrenal tumours, while an excess of exogenous corticosteroids can result from steroid treatments for asthma, chronic obstructive pulmonary disease, and inflammatory processes such as polymyositis.
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Muscle atrophy
Types of Muscle Atrophy
There are three types of muscle atrophy: physiologic, pathologic, and neurogenic. Physiologic atrophy, also known as disuse atrophy, is caused by insufficient muscle use. This can be due to a sedentary lifestyle, desk jobs, health problems that limit movement, or age-related factors. Physiologic atrophy can often be reversed through exercise and improved nutrition.
Pathologic atrophy is associated with aging, starvation, and diseases such as Cushing's disease, which can be caused by prolonged corticosteroid use or overactive adrenal glands. Cushing's disease can lead to a constellation of symptoms, including muscle weakness and atrophy.
Neurogenic atrophy is the most severe form of muscle atrophy. It is caused by injuries or diseases affecting the nerves that connect to the muscles. When these nerves are damaged, they cannot trigger the necessary muscle contractions, leading to muscle breakdown and a decrease in size and strength. Examples of conditions that can cause neurogenic atrophy include amyotrophic lateral sclerosis (ALS), dermatomyositis, and Guillain-Barré syndrome.
Symptoms of Muscle Atrophy
The symptoms of muscle atrophy vary depending on the underlying cause. Common signs and symptoms include:
- Reduced muscle mass, with one limb being noticeably smaller than the other.
- Weakness, numbness, and tingling sensations in the limbs.
- Difficulty with walking, balancing, swallowing, or speaking.
- Facial weakness and gradual memory loss.
Diagnosis and Treatment
The diagnosis of muscle atrophy typically involves a physical examination, medical history assessment, and specific tests. Treatment options depend on the underlying cause and may include physical therapy, ultrasound therapy, surgery, and addressing any underlying medical conditions. Disuse atrophy can often be reversed through regular exercise, proper nutrition, and, in some cases, swimming pool exercises to reduce muscle workload.
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Treatment options
Steroid Withdrawal/Tapering
The first line of treatment for steroid-induced myopathy is to reduce or, ideally, stop taking steroids. Tapered steroid withdrawal is critical for patients on chronic steroid therapy to prevent adverse effects like adrenal insufficiency or exacerbation of the primary illness.
Switching Steroid Type
If steroid withdrawal is not possible, an alternative is to switch to a different type of steroid. For example, replacing fluorinated glucocorticoids with non-fluorinated glucocorticoids such as replacing dexamethasone with prednisone or hydrocortisone.
Altering Dosage
Adjusting the dosage of steroids by reducing the amount or changing to alternate-day dosing can help manage muscle weakness.
Physical Therapy
Physical therapy, including resistance and endurance exercises, can effectively prevent and treat steroid-induced myopathy. Range-of-motion exercises, stretching, bed mobility, balance activities, transfer training, and gait training can improve mobility and prevent joint contractures. High-intensity exercises should be avoided due to potential harm.
Experimental Agents
While not yet recommended for humans, experimental agents such as exogenous IGF-I, branched-chain amino acids, creatine, androgens (testosterone, DHEA), and glutamine have shown promise in animal models.
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Risk factors
Corticosteroid-induced myopathy is a highly prevalent toxic noninflammatory myopathy that occurs as an adverse effect of prolonged oral or intravenous glucocorticoid use. It is believed that an excess of either endogenous or exogenous corticosteroids causes the condition. Endogenous corticosteroid excess can be caused by adrenal tumours, while exogenous corticosteroid excess can result from steroid treatments for asthma, chronic obstructive pulmonary disease, and inflammatory processes such as polymyositis, connective tissue disorders, and rheumatoid arthritis.
The risk of developing myopathy is higher in older patients, males, and those with obesity. Women, however, are twice as likely as men to develop muscle weakness from a given dose of steroids, although the reason for this is unclear.
The muscles most affected by steroid-induced myopathy are those in the arms, legs, and pelvis. Patients with this condition may experience a progressive inability to rise from chairs, climb stairs, and perform overhead activities. They may also develop Cushing syndrome stigmata, such as moon facies and fat redistribution, as well as metabolic complications, including obesity, diabetes, adrenal insufficiency, hyperlipidemia, hypertension, skin, and bone disorders.
In addition to these risks, there is also a possibility of acute steroid-induced myopathy, which can occur within days of starting treatment with high-dose corticosteroids. This acute form of myopathy can even be triggered by a single dose of intra-articular injection, as reported in a case study.
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Frequently asked questions
Steroid-induced myopathy is a toxic noninflammatory myopathy that occurs as an adverse effect of prolonged oral or intravenous glucocorticoid use. It causes muscle weakness, predominantly affecting the pelvic girdle muscles.
Patients with steroid-induced myopathy experience progressive muscle weakness, particularly in the upper and lower limbs, which makes it difficult to rise from chairs, climb stairs, and perform overhead activities. They may also experience Cushing syndrome stigmata, metabolic complications, increased susceptibility to infection, gastritis, cataracts, glaucoma, and mood/neurocognitive side effects.
The treatment for steroid-induced myopathy is to reduce or discontinue the use of steroids. In some cases, switching to a different type of steroid or altering the dosage may be recommended. Physical therapy, including resistance and aerobic exercises, can also help prevent and treat the condition.
The exact incidence of steroid-induced myopathy is unknown. However, one study found that muscle weakness developed in 47.5% of patients with an autoimmune blistering disease who were treated with glucocorticoids. The risk of developing myopathy is higher in older individuals, males, and those with obesity.
