Corticosteroids, Part 2 Print E-mail



How to Use Steroids

Because of the side effects that must be dealt with, though, steroids should only be added to your drug regimen if the highest tolerable doses of all other available medications cannot control your symptoms adequately. And they should be discontinuedor at least reducedas soon as it is appropriate to do so.

When during the day you take your steroid preparation, and how much you take, are extremely important in minimizing an otherwise critical side effect. Remember that the natural production of steroids temporarily cuts off the pituitary gland's production of ACTH. And until ACTH starts up again, no further steroids are produced.

Steroid drugs participate in this negative feedback cycle because the pituitary gland does not distinguish between natural and synthetic steroids. So when you start taking a steroid drug, the pituitary gland immediately decreases or stops its production of ACTH. This means that the adrenal glands decrease or stop producing steroids. Your body's own source of steroids temporarily dries up, so to speak. But this effect will be minimized if your dose schedule is properly dovetailed with your body's natural steroid-production rhythm. Taking steroids in the morning which is the high point of ACTH productioninterferes the least with the adrenal glands' natural activity.

Only minor interference occurs when steroid therapy lasts for just a few daysand this disappears rapidly as soon as the drug is stopped. Natural steroid suppression is greater, and lasts longer, as both dose level and length of therapy increase. (No one is sure, though, at exactly what drug dosage such suppression begins.) After a relatively short course of steroid medication, it takes about three days for the adrenal glands to resume their normal steroid activity. But if steroid treatment lasts for months or years, it may take six months or more before the adrenal glands are functioning normally again.

Because there is always a time gap between ending steroid treatment and the body's resumption of its own steroid production, the drug should never be ended abruptly. It should be tapered off little by little as the adrenal glands gradually regain their capacity to produce the amount of steroids normally needed.

Only several days are needed to taper off after a relatively short, low-dose treatment. But as dose and/or length increase, the tapering-off time becomes proportionately longer.

Short-term steroid therapy consists of one dose each morning for four to ten days. If longer treatment is needed, one dose is taken only every other morning. But if symptoms start to break through, then a daily morning dose must be tried. If symptoms still reappear between doses, the only alternative left is taking several doses spread over the day. This should be changed to one of the less frequent schedules as soon as symptom control improves.

Administration

Steroids can be taken orally or by injection, or by using an MDI to deliver them directly to the airways. Since an inhaled steroid penetrates into the lungs most effectively when the airways are dilated, it should be used 5 to 15 minutes after an inhaled bronchodilator.

Oral preparations are used far more often than injected steroids. The most common oral steroids are prednisone, prednisolone, and methylprednisolone. Because prednisone is changed to prednisolone once the body metabolizes it, some experts feel that using prednisolone or methylprednisolone to start with makes it easier to predict the blood concentration of this drug that a particular dose will achieve. Methylprednisolone may also have better inflammatory properties than the other two, and it definitely causes less salt retention. (Salt increase in the body can raise blood pressure.)

Using inhaled steroids dramatically reduces the frequency and severity of side effects. This is in part the nature of an inhaled drug, and partly becausefor patients with asthmainhaled steroids clearly help reduce the need for oral forms of the drug. For COPD patients in general, though, the few studies evaluating inhaled steroids show even fewer predictable benefits than oral steroids produce. In a recent study that followed stable COPD patients for 4 weeks of inhaled steroid treatment, only 25% of the overall group showed some degree of improvement, but 75% of those patients who also had a strong asthma component improved. Although some doctors now prescribe inhaled steroids to all their advanced COPD patients, this should really be done only for the patient who also has a strong asthma component.

The available inhaled steroid preparations are beclomethasone dipropionate (Vanceril and Beclovent), triamcinolone acetonide (Azmacort), and flunisolide (Aerobid).

Interactions with Other Drugs

Drugs That Affect Steroids: Certain drugs change the rate at which steroid drugs are removed from the body. Steroids are metabolized more quickly when they are taken together with barbiturates, ephedrine, and rifampin (a type of antibiotic). Steroids are metabolized more slowly when they are used at the same time as estrogen, certain other antibiotics, and the anti-allergy medication cromolyn sodium (although this effect is slight). In another type of effect, indocin (used in treating arthritis) increases steroids' potential for causing stomach ulcers.

Drugs Affected by Steroids: Steroids also affect other drugs. They enhance the action of beta-stimulating bronchodilators by preventing the beta-receptors from becoming less sensitive. Caution should be used when diabetic asthmatics use steroids, because they can dangerously reduce the action of the oral hypoglycemic medication many diabetics depend on. Taking steroids along with potassium-depleting diuretics increases the risk of dangerously lowering the body's potassium level. This in turn also increases the likelihood of toxicity for heart patients taking any of the cardiac glycosides (a group of heart medications that includes digitalis).

Side Effects

The exact nature and degree of these problems are determined by a variety of factors. These include each patient's individual biological reaction to steroids, the particular steroid preparation used, dosage size and schedule, and the useor lackof measures to counter specific effects.

The single most important side effect of inhaled steroids is thrush, which is a yeast infection in the mouth. It has occurred in up to 77% of oral steroid users. Large doses, diabetes, poor dental hygiene, and the simultaneous use of antibiotics all increase this risk. It is extremely important to gargle and rinse your mouth carefully with water after each inhaled dose.

The milder negative effects from all systemic steroids (referring to oral or injected preparations, because they travel throughout the body system) include increased appetite, some facial bloating, and acne. Moderate effects include leg cramps, insomnia, headaches, and unexplained mood changes.

The group of serious side effects includes such hazards as: skeletal muscle weakness (which responds to exercise); poor wound healing (countered by meticulous wound care plus vitamin A supplements); poor control of diabetes (countered by increasing the insulin or oral hypoglycemic agent); suppressed adrenal glands (countered by increasing steroid doses during stress); weakened immune response (countered by meticulous surveillance for infection); potassium loss (countered with potassium supplements); calcium loss from bones (minimized with calcium + vitamin D supplements and exercise). People who are susceptible to diabetes risk increasing the likelihood that they will develop it.

Stomach ulcers, gastric hemorrhage, intestinal tears, pancreatitis, cataracts, high blood pressure, and psychosis all require more sophisticated medical attention. And for COPD patients who already suffer from any one of these conditions, steroid drugs should be completely avoided if at all possible.


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