Corticosteroids, a gentle introduction!

-> At present, corticosteroids provide the best solution to asthma.

Frequently people have concerns about taking corticosteroid (steroid) medications because they are not well informed about their benefits, indications and risks. The following account of these drugs addresses some of the more frequently voiced apprehensions of the patients.

Corticosteroids are anti-inflammatory medications for the treatment of allergic conditions, asthma and other diseases. They are NOT the same as anabolic steroids, used by athletes to increase muscle tissue.

Corticosteroids are related to cortisol, a hormone produced by the adrenal glands and one of the body’s own natural steroids. Cortisol is essential for life and well being. During stress, our bodies produce additional cortisol to keep us from becoming seriously ill.

How Do Corticosteroids Work?

No one knows exactly how corticosteroids work. Studies show that their effectiveness in asthma may relate to their ability to:

  1. Decrease inflammation and swelling in the airways, lessening airway hyperreactivity;
  2. Reduce the release of body chemicals from certain inflammatory cells;
  3. Increase the effect of bronchodilator medications.

Corticosteroid Preparations:

Corticosteroid medications are available as nasal sprays, metered-dose-inhalers (inhaled steroids), oral forms (tablets or syrups), injections and intravenous (IV) solutions. The two most commonly prescribed forms of corticosteroids for most people with asthma are inhaled steroids and oral steroids.

i) Inhaled Corticosteroids

For most people with asthma, an inhaled corticosteroid is the primary medication that is used to prevent symptoms. When taken on a regular schedule, an inhaled corticosteroid reduces inflammation in the airways, making them less sensitive. Also, an inhaled corticosteroid may help reduce symptoms associated with chronic bronchitis or chronic obstructive pulmonary disease (COPD).

An inhaled corticosteroid is generally prescribed as a preventive medication. This means that you need to take it on a daily basis whether you have symptoms or not. Also, it will not provide immediate relief for breathing difficulty. Most people with asthma benefit from using an inhaled steroid year round, but those with seasonal asthma may need to use it for only certain months of the year.

Your physician may adjust the dosage of your inhaled corticosteroid based on your symptoms, how often you use your bronchodilator to control asthma symptoms and your peak flow results. You may continue to need an occasional short-term burst of oral steroids when you experience more severe episodes.

Available inhaled corticosteroids include:

  • Beclomethasone : Beclate (50, 100, 200, 250), Becoride (forte)
  • Fluticasone : Flohale (50, 125)
  • Budesonide : Budecort (100, 200), Budez (100, 200), Pulmicort

All the above steroids are effective. There is no definite superiority of one drug over the other. Any one may be used.

An inhaled corticosteroid has a low risk of side effects when used at recommended doses. Studies show that the medication is usually broken down by the liver and very little circulates in the blood stream, thereby decreasing the risk of significant side effects. When a dosage is prescribed that is higher than recommended in the package insert, some systemic side effects could occur. Keep in mind, however, that an inhaled steroid has much less potential for side effects than oral (tablet or syrup) steroids.

Common side-effects of inhaled corticosteroids and how to prevent these:

The most common side effects with inhaled corticosteroids are cough, hoarseness or a yeast infection of the mouth or throat (thrush). These can be prevented by:

  • Using a spacer device
  • Rinsing your mouth with water after use. Taking the inhaler just before breakfast and before dinner is a very effective way of preventing these.

ii) Oral steroids

Oral steroids are more common in tablet form. They are given as a short-term burst or as routine maintenance therapy. Although there are several steroid tablets available, prednisolone is the most commonly prescribed drug because it is short-acting and reliably well-absorbed and available to the lungs.

A short-term burst is generally used for severe asthma episodes. A burst may last three to seven days and not require a gradually decreasing dosage. Rarely, a burst may need to continue for several weeks with a gradually decreasing dosage (taper). Your health care provider should closely monitor bursts and tapers.

Side effects that may be associated with a burst include mood swings, swelling, increased appetite, flushing of the face and high blood pressure. These side effects usually disappear when the medication is stopped.

Important Considerations when your dosage of oral steroids changes:

As the control of your disease improves, or if serious side effects develop, your health care provider may reduce your steroid dosage by tapering to prevent ‘breakthrough’ symptoms and to allow the adrenal glands time to function again. Because the dose is highly individualized, follow your health care provider’s recommendations.

As your body adjusts to a lower steroid dosage, you may experience some withdrawal side effects. These may include an increase in breathing difficulty due to worsening of your disease, fatigue, weakness, depression and joint aches. If breathing difficulty occurs, or if any of the above symptoms are severe, notify your health care provider. The non-respiratory side effects usually disappear within a few weeks or months.

If your steroid dosage has recently been decreased or discontinued and you experience a serious illness, surgery or injury, you may temporarily require additional steroids. During this time, your adrenal glands may not be functioning at full capacity and cannot handle stress to the body. This is especially important if you have taken routine maintenance oral steroid therapy within the last year or completed a burst within the past two weeks. Inform your physician that you have been on corticosteroid treatment. Some people choose to wear a medical alert bracelet or carry a card with specific information about their steroid use.

Long-term Oral Corticosteroid use:

A small percentage of persons with chronic severe asthma require the use of oral steroids for prolonged periods, possibly weeks, months or longer. The treatment program should include a combination of several medications rather than oral steroids alone.

Common side effects of long-term Oral Corticosteroid use:

Steroid side effects usually occur after prolonged use with high doses. It is important to note that some people who take long-term oral corticosteroids experience only minimal side effects. Side effects which may occur in some persons taking high-dose oral steroids include:

  • Thinning of bones (osteoporosis) which may lead to fractures or compressions, especially of the vertebral bones (backbone) and the hip
  • Loss of blood supply to bones (aseptic necrosis) which may cause severe bone pain and may require surgical correction
  • High blood pressure (hypertension)
  • Increased pressure in the eye (glaucoma)
  • Permanent clouding of vision in one or both eyes (cataracts)
  • Weight gain with increased appetite, fluid retention and stretch marks
  • Facial fullness
  • Increase in body hair and acne
  • A tendency to easy bruising and thinning of the skin, along with poor wound healing
  • Interference with growth in children (remember that an untreated chronic illness can impair growth as well)
  • Muscle weakness or cramps, and joint pain
  • Changes in menstrual cycle
  • Elevations in blood sugar (diabetes)
  • Suppression of the body’s adrenal gland which makes the necessary amount of cortisol at times of stress (adrenal insufficiency). The adrenal gland function usually resumes when steroids are stopped or when they are taken in a single AM dose or a single PM dose every other day
  • Irritation of stomach and esophagus with possible ulcer symptoms and, rarely, bleeding
  • Emotional disturbances such as irritability, depression, euphoria or hallucinations
  • Steroids may also suppress your body’s response to certain viral infections, for example varicella (chickenpox). If you or your child are exposed and susceptible to chickenpox while receiving oral steroids or high dose inhaled steroids, notify your health care provider immediately to determine if any special treatment is needed.

Prevention of side effects with long-term oral corticosteroids:

  • Take the steroid dose as a single dose in the morning, as this is closer to how the body produces its own natural steroid. (Some individuals receive greater benefit from a mid afternoon, evening or split dose.)
  • If prescribed by your physician, take the steroid every other day to minimize side effects.
  • Take your steroid dose with food to lessen irritation of the stomach lining.
  • Take the full dosage (complete number of puffs) of your inhaled steroid as prescribed to allow the lowest possible dosage of oral steroids.
  • If you notice a deterioration in peak flows or increased symptoms, notify your health care provider. A short course of oral steroids given early may help alleviate the need for longer courses if treated later.

-> It is extremely important to follow your physician’s directions. Don’t make any changes without his/her approval!

-> The side-effects mentioned above are not observed with inhaled steroids.

Diet Recommendations for patients on long-term oral steroids:

  • Make sure you get proper nutrition when taking oral corticosteroids. Oral steroid use can cause you to lose calcium and potassium, important minerals for bone strength and good muscle function. An imbalance of these minerals may cause muscle cramping or heart irregularities. Don’t take a potassium supplement unless prescribed by your clinician. To make sure that you are getting enough calcium, increase your intake of dairy products to 4-5 servings per day.
  • If you experience swelling, your clinician may recommend a diet low in sodium. This may include limited use of salt or sodium-rich condiments and processed foods. Eat a well-balanced diet including citrus fruits and fruit juices.
  • Remember that corticosteroids can increase your appetite, so if you are eating more food, be sure you choose low-fat, lowsugar items to control calories.

Osteoporosis and long-term oral steroids:

Long-term oral corticosteroid use depletes the bones of calcium which can lead to osteoporosis. Osteoporosis, or brittle bones, places you at greater risk of fractures. Even low-dose corticosteroid therapy can cause this calcium loss; post-menopausal women are at particular risk. If you have osteoporosis or a family history of it, inform your physician.

Several tests can determine the extent of bone loss. These include laboratory calcium tests to measure the amount of calcium in the blood or urine, CT scans and bone densitometry. Bone densitometry is much more sensitive than routine X-ray of the bone. After a baseline measurement of bone density is determined, your clinician may want to repeat this test every 6-12 months for children and 12-18 months for adults to monitor possible mineral loss.

Regular weight-bearing exercise and supplemental calcium can reduce the risk of osteoporosis. Weight-bearing activities include walking, running and bicycling. Supplements of calcium and vitamin D may be recommended if your diet doesn’t supply the required amount. Discuss your particular needs with your health care provider.

Newer treatments to prevent steroid-induced bone loss include the injections thyrocalcitonin and etidronate. The majority of post-menopausal women on corticosteroid therapy benefit from estrogen replacement to prevent or lessen osteoporosis.

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