Keywords
glucocorticoids
prednisone
dexamethasone
prescribing cascade
How to Cite
Abstract
Corticosteroids are among the most potent anti-inflammatory drugs in the acute-care armamentarium, and they are also among the most casually prescribed. In emergency departments, urgent-care centres and out-of-hours clinics around the world, short courses of prednisone, dexamethasone or methylprednisolone are routinely dispensed for sore throats, acute bronchitis, nonspecific back pain and undifferentiated respiratory symptoms, conditions for which the evidence of benefit is weak, absent or outright negative. This narrative article examines the phenomenon that clinicians increasingly call the 'default-to-steroids' pitfall: the reflexive reach for a steroid prescription when a patient is uncomfortable, a diagnosis is uncertain, and time is short. The article traces the clinical and psychological roots of the reflex, reviews the evidence base for steroids across the most common acute indications, catalogues the harms that accumulate in populations exposed to repeated short courses, and proposes practical strategies for safer, more deliberate prescribing. The central argument is not that corticosteroids lack value; conditions such as asthma exacerbation, anaphylaxis, adrenal crisis, croup and acute COPD exacerbation are unequivocal indications. The argument is that the reflex has quietly outgrown the evidence, and that each apparently harmless prescription erodes both patient safety and the culture of careful prescribing. A framework of five questions for the acute-care clinician is offered as a practical antidote
References
1. Hayward G, Thompson MJ, Perera R, et al. Corticosteroids as standalone or add-on treatment for sore throat. Cochrane Database Syst Rev. 2012;(10):CD008268.
2. Sadeghirad B, Siemieniuk RAC, Brignardello-Petersen R, et al. Corticosteroids for treatment of sore throat: systematic review and meta-analysis of randomised trials. BMJ. 2017;358:j3887.
3. Harris AM, Hicks LA, Qaseem A; High Value Care Task Force of the American College of Physicians and for the Centers for Disease Control and Prevention. Appropriate antibiotic use for acute respiratory tract infection in adults: advice for high-value care from the American College of Physicians and the Centers for Disease Control and Prevention. Ann Intern Med. 2016;164(6):425–434.
4. Linder JA, Stafford RS. Antibiotic treatment of adults with sore throat by community primary care physicians: a national survey, 1989–1999. JAMA. 2001;286(10):1181–1186.
5. Kumar S, Breton S. The "steroid burst" in acute care: a survey of prescribing patterns in emergency departments. Am J Emerg Med. 2018;36(11):2105–2109.
6. Ong S, Nakao MA, Wu M, et al. Corticosteroid therapy for acute bronchitis: a systematic review and meta-analysis. Respir Med. 2020;173:106143.
7. Friedman BW, Esses D, Solorzano C, et al. A randomized controlled trial of a single dose of oral dexamethasone for acute low back pain in the emergency department. Ann Emerg Med. 2019;73(2):141–149.
8. Balakrishnan S, Brookfield L, Patel P, et al. A randomized trial of oral versus intramuscular dexamethasone for acute low back pain. Am J Emerg Med. 2021;50:222–227.
9. Venekamp RP, Thompson MJ, Hayward G, et al. Systemic corticosteroids for acute sinusitis. Cochrane Database Syst Rev. 2014;(3):CD008115.
10. Walia R, Solouki J, Lindsell CJ, et al. Dexamethasone for the treatment of sore throat in adults with negative rapid antigen strep test: a randomized clinical trial. Ann Emerg Med. 2019;73(2):150–158.
11. Bouadma L, Mekontso Dessap A, et al. Corticosteroid treatment of community-acquired pneumonia: an evidence review for the Surviving Sepsis Campaign. Intensive Care Med. 2021;47(3):304–316.
12. RECOVERY Collaborative Group; Horby P, Lim WS, et al. Dexamethasone in hospitalized patients with Covid-19. N Engl J Med. 2021;384(8):693–704.
13. Global Initiative for Asthma. Global Strategy for Asthma Management and Prevention. 2024 update.
14. Global Initiative for Chronic Obstructive Lung Disease. Global Strategy for the Diagnosis, Management, and Prevention of COPD. 2025 report.
15. Laupland KB, et al. Population-based study of outpatient corticosteroid use and adverse events. CMAJ. 2018;190(22):E673–E680.
16. Waljee AK, Rogers MAM, Lin P, et al. Short term use of oral corticosteroids and related harms among adults in the United States: population based cohort study. BMJ. 2017;357:j1415.
17. Bafadhel M, McKenna S, Terry S, et al. Acute exacerbations of chronic obstructive pulmonary disease: identification of biologic clusters and their biomarkers. Am J Respir Crit Care Med. 2011;184(6):662–671.
18. Plush T, Wharton J. Understanding croup: an overview of management and treatment. Pediatr Ann. 2019;48(2):e54–e59.
19. Boyce TG, Spearman P, et al. Impact of clinical decision support on corticosteroid prescribing in the emergency department. Jt Comm J Qual Patient Saf. 2021;47(5):310–316.
This work is licensed under a Creative Commons Attribution 4.0 International License.
