Corticosteroids are the most effective drugs used in the treatment of moderate to severe RA. Hydrocortisone and prednisolone are the two steroids most commonly used for the treatment of RA in Australia. They are derived from corticosteroid (or glucocorticoid) hormones produced by the adrenal gland which are essential for a range of bodily functions. They should not be confused with steroid sex hormones or with anabolic steroids used by body builders and athletes.
Corticosteroids have a wide range of actions but their major effect in RA is to suppress inflammation. They can be given as tablets, enemas, rectal foams, suppositories or intravenous injections, depending on the site and severity of inflammation. Rectal steroids (eg. Predsol®, Colifoam®) are preferred for disease confined to the lower large bowel because they are poorly absorbed into the blood and therefore produce fewer side-effects. There is no point in using rectal steroids for more extensive disease, as only part of the inflamed bowel will be treated.
Although steroids are the most effective treatment for more severe RA, their use is restricted by significant side-effects. Therefore high doses are used to bring attacks under control, after which they are gradually withdrawn over weeks to months. Steroids have no role in preventing flare-ups in those with inactive disease. However, a few patients with persistent "grumbling" disease require prolonged treatment with steroids. In these cases the lowest possible dose is used.
Side-Effects of Corticosteroids
Patients with IBD are often reluctant to take steroids because of their effects on bodily appearance. However, these side-effects do not always occur. The most common changes are weight gain (predominantly face and body - sometimes a "buffalo hump" of fat develops in the middle of the upper back), rounding (or "mooning") of the face, redness of the skin, acne, facial hair, easy bruising and ankle swelling. Rapid changes in weight can cause stretch marks. Some people develop wasting and weakness of the muscles of the upper arms and legs with long-term use. This can lead to difficulty with activities such as climbing stairs, getting out of a chair, combing hair or hanging out washing.
Many patients notice an increased appetite. Mood changes can also occur, usually a feeling of well-being but occasionally agitation, irritability or depression.
There are a number of less visible side-effects. Steroids weaken the body's resistance to infection. You should always consult your doctor if you develop an infection while you are taking steroids. They also cause thinning of the skin and impair healing after cuts or surgery.
Steroids may raise blood sugar levels; some people who have normal blood sugar levels develop diabetes while they are on steroids, those with pre-existing diabetes may have to increase their treatment. They can also raise blood pressure and lower the level of potassium in the blood, occasionally causing fatigue and weakness.
Prolonged use of steroids in children may retard growth. However, children with active IBD will not grow normally until the disease is brought under control. The long-term effects of withholding treatment are significantly greater than the side-effects of steroids. Children with IBD may experience a growth spurt after their disease is controlled.
All of the side-effects mentioned so far are reversible; they resolve when the steroids are stopped. There are also a small number of irreversible side-effects. These include development of cataracts and most importantly, bone damage. Corticosteroids can lead to osteoporosis, or softening of bones, with the result that bones break more easily. Osteoporosis develops gradually, particularly when high doses have been used for long periods of time and is more likely in those with other risk factors (eg. women after menopause). Rarely they cause a sudden loss of blood supply to the bone of the hip joint (avascular necrosis of the head of the femur).
The body's normal steroid production stops when you take corticosteroids. When an attack of IBD is under control the dose of steroids should be reduced gradually to allow the body to take over again. It may take up to 12 months to completely restore normal steroid production. As increased levels of corticosteroids are necessary for your body to cope with physical stresses such as surgery or illness, you should always tell your doctor, dentist or any paramedical person treating you if you have taken steroids over the previous 12 months. You should never stop steroids suddenly unless advised to do so by your doctor.