A handy guide to steroid therapy for arthritis

by Nathan Wei, MD, FACP, FACR

Nathan Wei is a nationally known board-certified rheumatologist and author of the Second Opinion Arthritis Treatment Kit. It's available exclusively at this website... not available in stores.

Click here: Second Opinion Arthritis Treatment Kit

Most forms of arthritis are characterized by inflammation involving joints.

Glucocorticoids – sometimes called corticosteroids or “cortisone” are among the most potent and rapidly acting anti inflammatory agents. Their beneficial effects are relatively short-term and are often overshadowed by the many potential side-effects.

Glucocorticoids are well absorbed orally. In the blood corticosteroids are highly protein bound.

There are many systemic effects of glucocorticoids. They decrease collagen synthesis and wound healing. They also promote the synthesis of glucose by the liver while at the same time increase the accumulation of glycogen (another form of sugar). They also inhibit the action of insulin, decrease the production of fat, while increasing the breakdown of fatty tissue. Protein is broken down at an accelerated rate in muscle. Corticosteroids also inhibit the absorption of calcium, and increase the excretion of calcium by the kidney.

Glucocorticoids act at several key points in the inflammatory cascade. Steroids interfere with the ability of inflammatory cells to collect and also block their passage through blood vessel walls. Communication between inflammatory cells is also blocked. Prostaglandin synthesis is interfered with. Powerful enzymes that white blood cells ordinarily release during inflammation (superoxides) are inhibited. Corticosteroids also reduce the synthesis of antibodies and suppress the immune response.

Adrenal glands normally produce corticosteroids in response to stress, infection, and inflammation.

While inhibiting inflammation is important in patients with arthritis, inflammation is a normal process in defense and repair. Therefore, while glucocorticoids block inflammation in arthritis, they also have undesireable side-effects.

They may increase the clearance of aspirin and can potentially reduce the effectiveness of warfarin. Patients on diuretics are at increased risk of losing excessive potassium. Patients with chronic diseases often do not synthesize enough albumin. This is an important protein that steroids are bound to. When there is less albumin, more free corticosteroid drug circulates with the potential for steroid toxicity.

Corticosteroids may interfere with vaccine therapy. This is important because the response to killed vaccine response is less than normal. By the same token, live vaccines may lead to side effects because the immune system is inhibited. Skin testing responses are also blocked.

Higher and more frequent doses of glucocorticoids mean more potent and faster effects on inflammation as well as more side-effects. Daily oral dosing in the morning is given to minimize the effect of adrenal suppression. Alternate day corticosteroids can be used for disease suppression during chronic therapy. Alternate therapy has fewer side-effects… but is also less potent.

For severe rheumatic diseases, a high dose short course of therapy, can be given over 1 to 3 days. One method used is intravenous pulse therapy. High doses (1,000 mgs.) of methylprednisolone (Solumedrol) is given daily for three days. This has a potent effect on chronic inflammation.

Glucocorticoids shut down adrenal corticosteroid production by affecting the pituitary adrenal axis. Since adrenal steroid production is impaired, the adrenal glands will not be able to respond in the face to outside stressors such as illness, surgery, infection, or trauma.

While alternate day therapy may decrease the risk of adrenal suppression, they do not remove it completely. Even short course or low dose corticosteroid therapy can lead to adrenal suppression.

Unfortunately the "good" effects of corticosteroids on inflammatory and immune responses also increase the risk of opportunistic infection.

The effects of steroids on glucose and protein metabolism leads to increased blood sugar, fat deposits in areas such as the face and neck, disturbances in electrolytes in the blood, fluid retention, hypertension and elevation of blood lipids.

Undesirable effects occur in the skin. These include, acne, excess hair, easy bruising, decreased ability to heal, and purple stretch marks.

In the eye, steroid therapy leads to cataracts and glaucoma.

Muscle weakness and wasting may develop. Ulcers in the stomach develop more readily, particularly in patients treated concurrently with non steroidal anti inflammatory drugs.

Pancreatitis is a complication as is accelerated hardening of the arteries.

Other side effects of corticosteroids include increased susceptibility to infection, osteonecrosis (death of bone), psychiatric disturbances, bowel perforation, and masking of infection.

Treatment with glucocorticoids needs to be individualized. One size does not fit all. Factors that need to be considered include: type of disease being treated, severity of condition, co-morbid conditions (other medical problems), and concomitant medications (other medicines).

The dose of corticosteroids needed should be the lowest dose required for control of the disease. Adjustments in dose will vary depending on clinical response as well as laboratory results.

Reductions in steroid dose need to be tailored to the situation. Abrupt decreases should be avoided since flares of disease may occur necessitating an increase in steroid dose and therefore prolongation of steroid therapy.

Once steroid dosing has reached an acceptable level (and that is dependent on the rheumatologist), then conversion to an alternate day schedule may begin.

Unfortunately, alternate dosing is not that effective for patient with rheumatoid arthritis and polymyalgia rheumatica.

The key is to control disease.

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