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The Facts Of Corticosteroids

Dateline: 05/13/98

In 1948, at the Mayo Clinic in Rochester, Minnesota a group of arthritis patients were given daily injections of a corticosteroid. The results were so striking and the improvement so dramatic that it was thought that the "cure" for arthritis had been discovered. As the use of corticosteroids expanded over the years, side effects emerged and it was realized that high doses given over prolonged periods of time turned steroids into "scare-oids". Patients were warned of the potential problems, the use of corticosteroids became more conservative, and some patients were so frightened of them they even declined treatment.

Corticosteroids are powerful drugs that can have valuable effect if administered within proper guidelines. Understanding how they work and how they can be safely taken is very important.

What are they?

Corticosteroids are drugs closely related to cortisol, a hormone which is naturally produced in the adrenal cortex (the outer layer of the adrenal gland). Cortisol plays an important part in controlling salt and water balance in the body, and regulating carbohydrate, fat, and protein metabolism. When the body becomes stressed, the pituitary gland at the base of the brain releases ACTH, adrenocorticotropic hormone, which stimulates adrenals to produce cortisol. The extra cortisol allows the body to cope with the stress such as infection, trauma, surgery, or emotional problems.When the stressful situation ends, adrenal hormone production returns to normal.The adrenal glands usually produce about 20 milligrams of cortisol per day, mostly in the morning, but can produce five times that much when needed.

How do they work?

Corticosteroids act on the immune system by blocking the production of substances that trigger allergic and inflammatory actions, such as prostaglandins. However, they also impede the function of white blood cells which destroy foreign bodies and help keep the immune system functioning properly. The interference with white blood cell function yields a side effect of increased susceptibility to infection.

Who should take them and how are they given?

Corticosteroids are used in the treatment of rheumatoid arthritis, systemic lupus erythematosus, polymyositis, polymyalgia rheumatica, and giant cell arteritis. They are not used systemically for osteoarthritis, though they are sometimes used as a local injection into an affected joint. Corticosteroids are versatile in their mode of application. They can be given orally, injected into the vein or muscle, applied locally to the skin, or injected directly into inflamed joints. Corticosteroids can be used in conjunction with other drugs, and are prescribed for short-term and long-term use.

Prednisone is the most commonly prescribed synthetic corticosteroid for arthritis. Prednisone is four to five times as potent as cortisol. Therefore, five milligrams of prednisone is the equivalent of the body's daily output of cortisol. There are other synthetic corticosteroids available which differ in potency and half-life.

Short-term vs. Long-term therapy

When used as a short-term treatment, prednisone is usually prescribed at a moderate dose and reduced or "tapered" over a one or two week period. The purpose is to achieve a sudden improvement in symptoms. Long-term therapy is usually reserved for severe cases of rheumatoid arthritis or related diseases. The doses are generally between 5 and 7 1/2 milligrams of prednisone a day continued over the course of months or years. High-dose steroids are given occasionally for the most rare, most severe cases of inflammatory disease. High-dose is considered daily doses of prednisone at 1 milligram per kilogram of body weight, or approximately 60 milligrams a day, given in divided doses. In such cases the steroids are "tapered" as soon as possible. To reduce potential side effects, the lowest dose of corticosteroid possible, still yielding a positive
impact, should be given.

Side Effects?

The potent effect of corticosteroids can result in serious side effects which mimic Cushing's disease, a malfunction of the adrenal glands resulting in an overproduction of cortisol. The list of potential side effects is long and includes: increased appetite and weight gain;
deposits of fat in chest, face, upper back, and stomach; water and salt retention leading to swelling and edema; high blood pressure; diabetes; osteoporosis; cataracts; acne; muscle weakness; thinning of the skin; increased susceptibility to infection; stomach ulcers; psychological problems such as depression; and adrenal suppression and crisis.

Side effects can be minimized by following doctor's orders and keeping to the lowest dose possible. It is also important to avoid self regulation of the dosage, either by adding more or stopping the medication without a schedule.

How do I stop the medication?

Steroids must be gradually reduced so as to permit the adrenal glands to resume natural cortisol production. If doses are eliminated too quickly adrenal insufficiency can result. In cases where corticosteroids were taken in low doses for long periods of time, tapering can continue for months or years. Sometimes doses are lowered one milligram at a time to prevent flare-ups. When steroids are taken for shorter periods of time, tapering is more rapid and decreases in dosage can be larger. Another possible complication to coming off steroids is steroid withdrawal syndrome, or rebound effect, which is the body's exaggerated response to removal of the drug. Rebound effect can result in fever, muscle pain, and joint pain making it hard for the physician to differentiate between
withdrawal symptoms and a flare of the disease itself.

Is injection better than oral corticosteroids?

Intra-articular therapy is the injection of steroids directly into an affected joint. This method allows doctors to use high doses of corticosteroids directly at the site of inflammation. Since it is localized, the rest of the body is spared the high concentration of the drug. Infection at the site of injection is a possible side effect.
Frequent injections into the same joint can also cause cartilage damage. Doctors use this treatment sparingly after other options have failed and attempt to limit the number of injections to every few months, and only a few altogether for a particular joint.

Corticosteroids are powerful drugs which can improve symptoms and provoke incredible results. There are potential consequences to their use though. The powerfulness of corticosteroids should not be feared, but must be respected.

The Duke University Medical Center Book Of Arthritis ,
David S. Pisetsky M.D.
Arthritis: What Works, Sobel & Klein

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