Corticosteroids (or, as they are more commonly known, “steroids”) are a class of medications that are often given to people with inflammatory diseases. These medications are similar to natural hormone substances that are produced by the body. Steroids help to reduce inflammation and have been used for more than 50 years to treat RA. They work by both decreasing inflammation and depressing the immune system (making it less active).
Steroids are very effective in decreasing symptoms of joint pain, swelling, and stiffness. In fact, recent studies report that taking at least three months of treatment with low-dose oral corticosteroids significantly reduces pain and joint inflammation while improving joint function. These medications can reduce your level of fatigue and rapidly improve your overall symptoms. Your doctor may prescribe steroids either to control painful flares of arthritis or to act as a “bridge” therapy until a slower-acting medication takes effect.
Steroids can be given as pills, intramuscular injections, or intravenous infusions. They can even be injected directly into inflamed joints. Names of commonly used steroid medications include betamethasone, budesonide, cortisone, dexamethasone, flunisolide, fluticasone, hydrocortisone, prednisone, prednisolone, and methylprednisolone.
Physicians often prescribe steroids for short periods (two to three months), with the objective of suppressing generalized arthritic flares or as temporary adjunctive therapy while waiting for the other medications (DMARDs or biologic agents) to exert their anti-inflammatory effects. Alternatively, physicians may prescribe steroids for longer periods (two years or more) in an attempt to modify the progression of RA and prevent destruction of the joints. For patients with severe disease, whose symptoms are not well controlled on maximal doses of NSAIDs, DMARDs, or biologic therapies, corticosteroids can be useful as chronic adjunctive therapy.
Corticosteroids often provide rapid, dramatic relief of the pain and inflammation caused by RA. Unfortunately, as with many other arthritis medications, joints often become inflamed again after corticosteroids are discontinued, unless the patient also takes DMARDs.
Corticosteroids often provide rapid, dramatic relief of the pain and inflammation caused by RA. Unfortunately, long-term use of steroids can have serious side effects.
These serious side effects include:
- Destruction of the hip, knee, wrist, or foot joints (osteonecrosis)
- Bone thinning and weakening (osteoporosis)
- Cataracts
- Swelling caused by fluid retention (edema)
- Weight gain
- Acne
- Rounding of facial features (moon face)
- Mood swings, depression, difficulty concentrating, insomnia, anxiety, and euphoria
- Easy bruising
- Increased risk of infection from immune suppression
- Elevated blood pressure
- Elevated blood sugar levels (diabetes)
- Muscle weakness
- Glaucoma
As with any medication, you must weigh the risks of taking a steroid against the benefits it offers. Steroids' side effects usually occur when higher dosages are given over a long period of time (weeks to months); most people who use steroids for only a short period of time do not suffer side effects. You should discuss the benefits and risks of taking steroids with your physician before filling the prescription. A good goal to keep in mind is summarized in this way: the smallest possible dose, for the shortest duration of time. Patients with RA frequently take small doses of steroids, but for long periods of time.
One potentially serious side effect of long-term steroid use is adrenal suppression. Under normal circumstances, the body's adrenal system produces cortisol (a naturally produced steroid); the brain, in turn, monitors the cortisol levels in the bloodstream. The brain cannot tell the difference between the body's own cortisol and the steroid medication provided by the doctor, however. Thus the adrenal gland, because it is no longer called upon to produce natural steroids, may shut down. Over time, a person who is taking high doses of steroids may become unable to rapidly produce natural steroids from his or her adrenal gland. If your doctor is uncertain about whether you will be able to taper off steroids after a long period of treatment owing to adrenal suppression, the doctor might recommend that you take a cortrosyn stimulation test. This test can determine whether your adrenal glands still retain the ability to produce cortisol.
If you take steroids for a long time, your doctor may recommend that you take a larger dose of steroids before you undergo surgery, after a serious accident, or in a stressful situation. This larger dose is intended to compensate for your body's inability to increase its natural steroid production to the level necessary to tolerate these stresses. The increased steroid levels during stress allow the body to maintain blood pressure and normal heart function. When you and your doctor determine that you no longer require the steroids, your physician will gradually lower the dose you're taking, allowing your own adrenal gland to slowly increase its production to normal levels.
This phenomenon explains why it is so important that you continue taking steroid medications regularly and do not stop their use abruptly. Even if you don't have any refills left on your prescription, it is a good idea to check with your doctor and confirm that the doctor intended for you to stop treatment. If you have any doubts about what you should do, ask your doctor.
There are a few things you can do to limit the side effects of steroids—specifically, go on a low-calorie, low-salt diet; make sure that you consume an adequate amount of vitamin D and calcium; and get enough weight-bearing exercise. You should discuss all of these issues with your physician, who can make specific recommendations about diet and exercise. In addition, your doctor may prescribe other medications that will help prevent bone loss, such as Actonel, Fosamax, Boniva, or calcitonin. Patients with and without osteoporosis risk factors who are taking low-dose prednisone should also undergo bone densitometry tests to assess their fracture risk.
Corticosteroids—I have had cortisone injections in the knees, hands, and the shoulders. They work for about a 30-day period. Just enough time to get me through the flare up.
—Jim
Prednisone was my best friend for many years. I was usually prescribed a low dose in combination with other medications. Any time I had a bad flare up—my right hand could really swell to the point where I couldn't use it. I could count on a steroid packet to give me relief within about 24 hours. But I also knew that long term use of steroids can have serious side effects. Despite this, it was worth it to get rid of my symptoms.
—Nona