Quick Answer
Corticosteroids are one of the highest-yield NEET PG pharmacology topics because they touch every clinical rotation.
- HPA axis — hypothalamic CRH triggers pituitary ACTH which drives adrenal cortisol; normal endogenous cortisol is 15 to 25 mg/day, roughly equivalent to 5 to 7.5 mg prednisolone.
- Potency equivalence — 20 mg hydrocortisone equals 5 mg prednisolone equals 0.75 mg dexamethasone in glucocorticoid activity.
- Signature adverse effects — Cushingoid habitus, hyperglycaemia, hypertension, osteoporosis, cataract, peptic ulcer, infection, psychiatric, HPA suppression, growth failure in children.
- Never stop abruptly — taper if over 2 weeks or high dose; give stress-dose steroids for surgery.
- Bone protection — calcium plus vitamin D plus bisphosphonate for over 3 months of over 5 mg prednisolone.
- Dexamethasone in COVID-19 — RECOVERY trial 2020 established mortality benefit in oxygen-requiring patients.
- India context — massive OTC misuse; iatrogenic Cushing, steroid-induced diabetes, TB reactivation.
Corticosteroids are the single most prescribed class of anti-inflammatory drug worldwide, and NEET PG loves the topic because it links endocrine physiology to almost every specialty — pulmonology (asthma, COVID-19), rheumatology (SLE, vasculitis), gastroenterology (IBD), oncology (lymphoma, brain oedema), dermatology, nephrology (nephrotic syndrome), obstetrics (fetal lung maturation) and paediatrics (croup, CAH).
This NEETPGAI deep dive covers HPA-axis physiology, potency equivalence, clinical indications, the full adverse-effect ladder, tapering, monitoring, adjunct therapy and the India-specific misuse problem. Pair this with the NSAIDs and analgesics pharmacology guide for the broader anti-inflammatory landscape.
HPA axis and endogenous cortisol
The hypothalamic-pituitary-adrenal (HPA) axis regulates cortisol secretion. Hypothalamic corticotropin-releasing hormone (CRH) stimulates pituitary ACTH release, which drives adrenal zona fasciculata cortisol production. Cortisol exerts negative feedback on both CRH and ACTH.
Cortisol has a strong circadian rhythm with a peak in the early morning (around 8 am) and a nadir around midnight. Physiologic cortisol production is approximately 15 to 25 mg per day, roughly equivalent to 5 to 7.5 mg prednisolone. This is why doses in that range are termed "physiologic replacement" while higher doses are "pharmacologic".
Understanding the axis matters clinically because exogenous glucocorticoids suppress CRH and ACTH; prolonged suppression atrophies the adrenal cortex, so abrupt withdrawal or major stress in a suppressed patient precipitates adrenal crisis.
Glucocorticoid pharmacology and potency
The available glucocorticoids differ in glucocorticoid activity, mineralocorticoid activity and duration of action.
| Drug | GC potency (equiv dose) | MC activity | Duration | Notes |
|---|
| Hydrocortisone | 1x (20 mg) | 1x | Short (8 to 12 h) | Replacement therapy; IV in shock |
| Cortisone | 0.8x (25 mg) | 0.8x | Short | Pro-drug |
| Prednisone | 4x (5 mg) | 0.8x | Intermediate (12 to 36 h) | Converted to prednisolone in liver |
| Prednisolone | 4x (5 mg) | 0.8x | Intermediate | Preferred in liver disease |
| Methylprednisolone | 5x (4 mg) | Minimal | Intermediate | IV pulse therapy in vasculitis |
| Triamcinolone | 5x (4 mg) | 0 | Intermediate | Intra-articular, dermatologic |
| Dexamethasone | 25 to 30x (0.75 mg) | 0 | Long (36 to 72 h) | Cerebral oedema, antenatal maturation, COVID-19 |
| Betamethasone | 25 to 30x (0.6 mg) | 0 | Long | Antenatal maturation, dermatologic |
Preparations — oral tablets, IV, IM depot (triamcinolone, methylprednisolone acetate), topical (potency ladder from hydrocortisone 1 percent to clobetasol propionate 0.05 percent ultra-potent), inhaled (budesonide, fluticasone, beclomethasone, ciclesonide, mometasone), intranasal, ophthalmic (dexamethasone, prednisolone acetate, loteprednol), intra-articular and intralesional.
Mechanism of action
Glucocorticoids diffuse into cells, bind the cytoplasmic glucocorticoid receptor (GR), translocate to the nucleus and alter transcription of hundreds of genes — the "genomic" pathway with a slow onset over hours to days.
Anti-inflammatory and immunosuppressive actions:
- Inhibit phospholipase A2 (via lipocortin-1 induction) — reduces arachidonic acid release upstream of both COX and LOX.
- Suppress NF-kB — reduces cytokine, chemokine and adhesion molecule expression.
- Deplete circulating lymphocytes, eosinophils, basophils, monocytes; demarginate neutrophils (leukocytosis).
- Reduce capillary permeability and vascular leak.
- Inhibit fibroblast proliferation and collagen deposition.
- Rapid non-genomic effects (minutes) mediated by membrane receptors — relevant in acute severe asthma and anaphylaxis.
Clinical indications
Glucocorticoids are indicated across almost every specialty.
- Autoimmune and rheumatologic — SLE, RA (bridging therapy), vasculitis (GPA, MPA, EGPA, giant cell arteritis, PAN), polymyalgia rheumatica, IBD (Crohn, ulcerative colitis), autoimmune hepatitis.
- Allergic and hypersensitivity — anaphylaxis (adjunct after adrenaline), asthma (inhaled maintenance, oral for exacerbations), atopic dermatitis, drug reactions.
- Respiratory — COPD exacerbation, asthma exacerbation, ARDS, croup, COVID-19 (dexamethasone).
- Transplantation — induction and rejection therapy.
- Oncology — lymphoma and leukaemia (part of CHOP, EPOCH), brain oedema (metastases, primary tumours), spinal cord compression, chemotherapy-induced nausea and vomiting.
- Adrenal insufficiency — physiologic replacement (hydrocortisone plus fludrocortisone in primary AI).
- Septic shock — hydrocortisone 200 mg/day in vasopressor-dependent shock (SURVIVING SEPSIS 2021).
- Congenital adrenal hyperplasia — hydrocortisone in children, prednisolone or dexamethasone in adults.
- Nephrology — nephrotic syndrome (especially minimal change disease in children).
- Obstetrics — antenatal betamethasone or dexamethasone at 24 to 34 weeks for fetal lung maturation; also given up to 36 weeks 6 days in select settings.
- Neurology — MS relapse (IV methylprednisolone pulses), TB meningitis (adjunct dexamethasone), acute traumatic spinal cord injury (controversial; not routinely recommended).
- Dermatology — pemphigus, bullous pemphigoid, severe eczema, psoriasis (systemic reserved due to rebound).
Adverse effects (the exam checklist)
- Cushingoid habitus — moon face, buffalo hump, central obesity, thin extremities, purple striae, easy bruising, muscle wasting, hirsutism.
- Metabolic — hyperglycaemia, new-onset diabetes, insulin resistance, dyslipidaemia.
- Cardiovascular — hypertension, fluid retention, hypokalaemia (via mineralocorticoid activity in short-acting agents), oedema.
- Musculoskeletal — osteoporosis (via reduced osteoblast activity and calcium malabsorption), avascular necrosis of the femoral head, vertebral compression fractures, proximal myopathy.
- Ocular — posterior subcapsular cataracts, open-angle glaucoma, delayed corneal healing.
- Gastrointestinal — increased peptic ulcer risk especially with concurrent NSAIDs; pancreatitis reported.
- Infection — bacterial, fungal (Candida, Pneumocystis), reactivation of TB and hepatitis B; PCP prophylaxis with TMP-SMX at doses of 20 mg prednisolone or more for 1 month or longer.
- Skin — thinning, striae, delayed wound healing, purpura, acne.
- Psychiatric — mania (early), depression (later), psychosis, insomnia, cognitive change.
- HPA axis suppression — after 2 to 3 weeks of over 7.5 mg prednisolone; adrenal crisis on withdrawal or stress.
- Growth — suppression in children (dose-related); may partially recover after cessation.
- Immunological — decreased efficacy of vaccines while immunosuppressed; avoid live vaccines.
Tapering and stress-dose steroids
Any patient on more than the equivalent of 7.5 mg prednisolone daily for more than 2 to 3 weeks, or any dose for more than a month, needs tapering. Faster tapers in cases of shorter duration; slower in older patients or longer courses. Typical taper: reduce by 10 to 20 percent every 1 to 2 weeks based on dose, duration, and disease activity.
Stress-dose steroids are given to chronically steroid-treated patients undergoing surgery or facing major illness:
- Minor surgery — usual morning dose; may add 25 mg hydrocortisone IV pre-op.
- Moderate surgery — 50 mg hydrocortisone IV, then 25 mg every 8 hours for 24 hours.
- Major surgery — 100 mg hydrocortisone IV, then 50 mg every 8 hours for 24 to 48 hours, taper over days.
- Adrenal crisis — 100 mg hydrocortisone IV bolus, then 50 to 100 mg every 6 hours plus IV saline and dextrose.
Monitoring and adjunct therapy
- Blood pressure and weight at every visit.
- Blood glucose at baseline and periodically; consider HbA1c every 3 to 6 months.
- Bone density (DEXA) — baseline in high-risk patients; repeat every 1 to 2 years.
- Ophthalmology review — annually for cataract and glaucoma screening.
- Growth monitoring in children on chronic therapy.
- Infection screening — TB screen (Mantoux, IGRA or CXR) before high-dose or biologic-combined steroid therapy in India; hepatitis B and C serology; strongyloides serology in endemic areas before high-dose steroid.
- Adjunct therapy — calcium 1000 to 1200 mg per day plus vitamin D 800 to 1000 IU per day; bisphosphonate in patients on over 5 mg prednisolone for over 3 months who are at increased fracture risk (postmenopausal women, men over 50); PPI if concurrent NSAIDs or previous ulcer; TMP-SMX for PCP prophylaxis at sustained high doses; live vaccines contraindicated.
Special populations and situations
- Pregnancy — prednisolone is preferred (largely inactivated by placental 11-beta-HSD2); dexamethasone and betamethasone cross the placenta and are used specifically for fetal lung maturation.
- Lactation — prednisolone is compatible; dose over 20 mg per day should be timed after breastfeeds.
- Children — inhaled steroids may modestly reduce final adult height; use lowest effective dose.
- Liver disease — use prednisolone rather than prednisone (which needs hepatic conversion).
- Diabetes — anticipate hyperglycaemia; dose insulin proactively during pulse therapy.
NEET PG MCQ traps
- Equivalent doses — 20 mg hydrocortisone equals 5 mg prednisolone equals 0.75 mg dexamethasone.
- Dexamethasone — no mineralocorticoid activity; long half-life; crosses placenta.
- Prednisolone in liver disease — because prednisone needs hepatic conversion.
- Fetal lung maturation — betamethasone or dexamethasone at 24 to 34 weeks (extended to 36+6 in select cases).
- Adrenal crisis — IV hydrocortisone 100 mg plus saline and dextrose.
- Never stop abruptly — after over 2 to 3 weeks of over 7.5 mg prednisolone.
- Osteoporosis prevention — calcium plus vitamin D plus bisphosphonate for over 3 months of over 5 mg prednisolone.
- PCP prophylaxis — with sustained doses over 20 mg prednisolone for one month or more.
- Live vaccines — contraindicated on immunosuppressive doses.
- Cushingoid habitus — iatrogenic is far commoner than endogenous Cushing.
- RECOVERY trial — dexamethasone 6 mg daily reduced mortality in COVID-19 needing oxygen or ventilation.
- SURVIVING SEPSIS 2021 — hydrocortisone 200 mg/day in vasopressor-dependent septic shock.
- Croup — single dose of oral dexamethasone.
- Bell palsy — high-dose oral prednisolone within 72 hours.
- Minimal change disease — high-dose prednisolone; steroid-responsive.
- Giant cell arteritis — start high-dose prednisolone empirically before biopsy to prevent vision loss.
- AVN of femoral head — steroid-induced; MRI is the most sensitive test.
- Topical steroid potency — clobetasol propionate is ultra-potent; hydrocortisone 1 percent is the mildest.
- Inhaled corticosteroid side effects — oropharyngeal candidiasis, dysphonia; rinse mouth after use.
- Steroid-induced psychosis — most common in the first 2 weeks; dose-related.
Recent updates and India context
- RECOVERY trial (2020) — dexamethasone 6 mg daily for up to 10 days reduced 28-day mortality in COVID-19 patients requiring oxygen. No benefit and possible harm in those not requiring oxygen.
- SURVIVING SEPSIS 2021 — hydrocortisone 200 mg/day recommended in vasopressor-dependent septic shock.
- Antenatal steroids (WHO 2022) — recommended for imminent preterm birth at 24 to 34 weeks; considered at 34+0 to 36+6 in specific settings.
- JAK inhibitors as steroid-sparing — baricitinib, upadacitinib, tofacitinib reducing chronic steroid burden in RA, IBD and vitiligo.
- India OTC steroid misuse — topical combination creams (steroid plus antifungal plus antibiotic) drive an epidemic of tinea incognito; ICMR and IADVL advocacy pushing for stricter Schedule H regulation.
- Iatrogenic Cushing in India — a leading cause of secondary diabetes, hypertension and osteoporosis in tertiary endocrinology clinics.
- TB reactivation risk — screen all patients before high-dose or long-term steroid, especially before biologics; India NTEP integrates screening for high-risk cohorts.
- CFTR modulators and steroids — CF centres are reducing steroid burden as Trikafta improves airway inflammation directly.
Frequently asked questions
What are the standard glucocorticoid equivalent doses examiners test?
The classic equivalence — memorise it in one direction. 20 mg hydrocortisone equals 25 mg cortisone equals 5 mg prednisolone or prednisone equals 4 mg methylprednisolone or triamcinolone equals 0.75 mg dexamethasone equals 0.6 mg betamethasone in glucocorticoid activity. Hydrocortisone and cortisone retain significant mineralocorticoid activity; dexamethasone and betamethasone have essentially none. Duration of action also matters — hydrocortisone is short (8 to 12 hours), prednisolone intermediate (12 to 36 hours) and dexamethasone long (36 to 72 hours).
When should you never stop corticosteroids abruptly?
Never stop abruptly if the patient has been on more than the equivalent of 7.5 mg prednisolone daily for more than 2 to 3 weeks, or any dose for over a month. HPA axis suppression means the adrenals cannot mount a stress response, and abrupt withdrawal precipitates adrenal crisis — hypotension, hypoglycaemia, hyperkalaemia, shock. Taper by 10 to 20 percent every 1 to 2 weeks depending on duration, cumulative dose and underlying disease, and give stress-dose steroids for surgery or major illness in any patient on long-term steroids.
What was the dexamethasone finding in the RECOVERY trial for COVID-19?
The RECOVERY trial published in the New England Journal of Medicine (2020) showed that dexamethasone 6 mg daily for up to 10 days reduced 28-day mortality by roughly one-third in mechanically ventilated COVID-19 patients and by one-fifth in those requiring supplemental oxygen. There was no benefit — and possible harm — in patients not requiring oxygen. Dexamethasone became the first drug proven to reduce COVID-19 mortality and reshaped global protocols including the Indian AIIMS guidelines.
How do you prevent glucocorticoid-induced osteoporosis?
Any patient starting the equivalent of 5 mg or more prednisolone daily for an expected duration of 3 months or more needs bone protection. Ensure adequate calcium (1000 to 1200 mg per day) and vitamin D (800 to 1000 IU per day). Assess fracture risk with FRAX and DEXA scan. Add a bisphosphonate (oral alendronate or risedronate; IV zoledronic acid if oral intolerance) in postmenopausal women, men over 50 and any high-risk patient. Denosumab and teriparatide are second-line options.
Why is steroid misuse a public-health concern in India?
Over-the-counter availability of oral and topical corticosteroids, unregulated prescriptions for skin lightening, joint pain, allergic rhinitis and non-specific fatigue drive widespread iatrogenic Cushing syndrome, steroid-induced diabetes, and tinea incognito (fungal infections masked by topical steroids). India also carries the world's highest TB burden, so sustained systemic steroid use risks TB reactivation. The Indian Association of Dermatologists Venereologists and Leprologists has campaigned for stronger regulation of topical steroid combinations.
This content is for educational purposes for NEET PG exam preparation. It is not a substitute for professional medical advice, diagnosis, or treatment. Clinical information has been reviewed by qualified medical professionals.
Written by: NEETPGAI Editorial Team
Reviewed by: Pending SME Review
Last reviewed: September 2026
