Corticosteroids

 

What are Corticosteroids?

Corticosteroids are also known as steroids. They are chemically made versions of the natural hormones released by the body in response to inflammation.

In inflammatory conditions, such as arthritis, the body’s immune system is over active. The immune systems normal function is to produce inflammation in response to infection and injury, to help with healing and to fight the infection. However over-activation in diseases results in excess inflammation, which is targeted at healthy tissue resulting in joint pain, swelling and redness.

Steroids can be used to dampen down this inflammation and reduce pain, swelling and redness. However they are not a long-term treatment due to a number of side effects with prolonged use.

 

What are Corticosteroids used for?

Steroids are used for a number of conditions that involve inflammation. They are usually given as a temporary treatment to reduce the inflammation present awaiting long-term treatments such as DMARDs taking effect. They are not a cure, but can improve symptoms in an acute flare.

 

How are they taken?

Steroids come in a number of forms:

• Tablets
  • Examples include- Prednisolone, dexamethasone
  • They are usually given as a short course for a week to help settle swollen joints. However in some conditions such as vasculitis, a more prolonged course can be given, starting at a high dose, reducing as the symptoms come under control.
  • The tablets are best taken first thing in the morning with food.
• Intravenous injections
  • This is via a drip into the vein
  • Examples include Methylprednisolone, hydrocortisone and dexamethasone
  • These are usually reserved for severe episodes of inflammation in patients that require hospital care and are too unwell for tablets.
  • A small dose can be given with infusions of biological DMARDs to prevent side effects
• Intramuscular injections
  • These are injections into the muscle (usually the buttock)
  • Examples include Depomedrone
  • They are often given in clinic if there are multiple swollen joints
• Intra-articular injections
  • These are steroid injections given into a joint space
  • They are given by the rheumatology team in clinic to help settle a swollen joint
• Topical treatments
  • Eye drops- often prescribed for inflammation in the eyes by specialists
  • Skin creams- for severe rashes, these are prescribed by GPs and skin specialists

 

Side effects

As steroids are used to suppress the immune system there are a few side effects to be aware of:

 

• Increased appetite, weight gain and stretch marks
  • A healthly lifestyle with well balanced meals and regular exercise can help.
• Indigestion and stomach pains
  • Tablets can often cause acid reflux and in severe cases, stomach ulcers.
  • A stomach lining tablet called omeprazole; lansoprazole or ranitidine is often prescribed at the same time to prevent excess stomach acid being produced.
• Bruising and skin thinning
  • Commoner with longer use and topical treatments.
• Disturbance of sleep
  • Insomnia can occur, try to take your medications early in the morning.
• Mood changes
  • Steroids can alter your mood, sometimes making you feel elated or low, it is commoner in people who have previously had problems with their mood.
• Osteoporosis in long term use
  • Thinning of the bones can occur if you are taking more than 12.5mg of steroids daily for more than 3 months.
  • If this is the case, if your risk is high, bone protection is prescribed to prevent this. This is usually a calcium and vitamin supplement along side a medication called a bisphosphonate.
• High blood pressure
  • Steroids can raise your blood pressure, if you are taking them for a prolonged period, your GP will monitor your blood pressure.
• Diabetes
  • Steroids can sometimes cause high blood sugars and diabetes in those that do not suffer from the condition.
  • Your blood sugars will be monitored whilst you are taking steroids and you may need to start medications or alter the doses you are on to control them.
• Infections
  • Taking steroids long term can weaken your immune system, making you more likely to catch infections.
  • If you are feeling unwell, speak to your GP or rheumatology team to let them know
  • Speak to your doctor if you develop shingles, chickenpox or other measles or if you come into contact with someone with these.
• Muscle weakness
  • Long-term use of steroids can cause loss of muscle mass resulting in weakness.
  • Ensure you continue to be as active as possible to prevent weakening of the muscles, particularly around the shoulders and hips.
• Eye changes
  • Glaucoma and cataracts are more common.
• Cushing’s syndrome
  • Exposure to steroids long term can cause problems with the hormone system resulting in weight gain, stretch marks, a rounded face and acne alongside other symptoms.
• Joint infections
  • Rarely injecting a joint with steroids can result in an infection being introduced into the joint space.
  • If you develop fevers and a very tender, painful, red, warm and swollen joint seek medical advice urgently.

 

Cautions of use

Interactions with other medications

• Steroids can interact with other medications such as epilepsy treatments and blood thinners. Your doctors and pharmacist will advice further.

Contraindications with other conditions

• If you have been taking steroids for a long time, it is important to never just stop them without your doctor’s advice. The body usually produces a low level of steroid, when you take steroid tablets, this normal function of the body can stop. Therefore stopping steroid tablets abruptly can cause severe side effects. If you feel unwell with symptoms such as fatigue nausea, dizziness and diarrhoea you should contact your doctor.
• Steroids should be slowly reduced down before stopping in these cases, occasionally the function of the bodies normal steroid production needs testing; your doctor will arrange a blood test if this is the case.
• When you are unwell with an infection and taking long-term steroids, your doctor may increase the dose whilst you are unwell to ensure that the normal body function is mimicked.

Operations

• You will need to let your rheumatology team and surgeon know that you are taking steroids. The team will decide what is best to do depending on how long you have been on them and the dose you are taking.

During pregnancy and breast feeding

• Steroids can be used during pregnancy and are often given for flares of disease when other medications have to be stopped.
• Steroids can pass into breast milk, however no research has shown it to be harmful to babies.

Alcohol

• Steroids and alcohol can both cause stomach upsets. Therefore to reduce the risk, it is recommend keeping within recommended units of less than 14 units weekly.

Vaccinations

• The flu and pneumonia vaccine are both safe to get when you are on steroids.
• The shingles vaccine can be given if you are on a low dose of steroids, however it is best discussed with your GP and rheumatology team.
• Live vaccines such as yellow fever should be discussed with your rheumatology team to assess the risks.

 

Useful Links

Versus Arthritis: http://www.versusarthritis.org