Corticosteroids may be used as part of the treatment in rheumatic disease. They have a disease-modifying effect in rheumatoid arthritis (RA), but they should not be used as the sole treatment. In polymayalgia rheumatica however, they are often the only effective treatment and may be used as a single agent. Adverse effects to steroids are related to the dose and duration of the treatment. Patients taking long-term treatment should be prescribed the lowest effective dose. Steroids should not be stopped abruptly.
Types of steroid
Oral preparations are often used as an adjunctive therapy to DMARDs (Disease Modifying Anti-Rheumatic Drugs). Intravenous preparations have a more restricted role in very ill patients. Steroids given directly into the joint (intra-articular), are commonly used for inflammatory rheumatic diseases eg. RA, psoriatic arthritis or juvenile arthritis and when given into an inflamed area (intra-lesional), can be helpful for example in bursitis. Different corticosteroids vary with respect to their duration and type of action.
Corticosteroids have a wide range of biological activity including anti-inflammatory and immunosuppressive effects. They have effects on the white blood cells and pro-inflammatory proteins called cytokines.
Steroids are usually used as part of ‘induction’ therapy in RA. DMARDs (such as methotrexate, salazopyrine and hydroxychloroquine) usually take 4-6 weeks to be fully effective and so an intramuscular injection of depomedrone (long acting steroid) is given monthly for the first 3 months to achieve a more rapid remission of the disease. Very occasionally in RA, steroids can be given by mouth.
Both polymyalgia rheumatica (PMR) and giant cell arteritis (GCA) are treated with oral corticosteroids. Lower doses (15mg) are usually used initially in PMR, whereas higher doses, e.g. 40-50 mg/day are used in GCA. The drugs are continued for a few weeks and then, depending on the symptoms and blood tests e.g. CRP, the dose can be very gradually reduced. Both conditions require treatment with steroids for a period of about two to five years.
Connective tissue diseases
Diseases such as systemic lupus erythematosus (SLE), vasculitis and polymyositis require systemic corticosteroid therapy for effective control. These diseases vary greatly in the extent and severity of organ system involvement so there is a need to individualise treatment. In severe flares, high-dose oral or intravenous corticosteroids maybe required. Management should be under the guidance of a rheumatologist experienced in treating these complex disorders.
Local corticosteroid therapy
An injection of a corticosteroid into the site of inflammation can avoid most of the problems caused by large oral doses. Intra-articular corticosteroids are used when a high concentration is required in a particular joint. Examples of these include RA, sero-negative spondyloarthritis, gout and osteoarthritis.
The indications for intra-lesional injections include bursitis, carpal tunnel syndrome and tendonitis.
Adverse effects of steroids
Corticosteroid therapy has many possible complications. The more common adverse effects with long-term use include:
- weight gain and Cushinghoid features e.g. moon face
- skin atrophy
- mood changes
Some of the adverse effects maybe more serious and require monitoring:
- elevation of blood glucose level, especially in diabetics
- high blood pressure
- increased susceptibility to infection
- avascular necrosis of bone
Withdrawal of corticosteroids
Patients treated with long-term moderate or low doses of corticosteroids should have their corticosteroid dose reduced and withdrawn slowly. The reasons for this are to:
- allow time for the hypothalamic-pituitary axis to recover as it can be suppressed by only 3 weeks of systemic treatment
- reduce the likelihood of relapse of the underlying condition being treated, particularly symptomatic inflammatory disease e.g. RA, PMR
- avoid the `corticosteroid withdrawal syndrome’ which some patients develop if their dose is suddenly reduced. Symptoms include myalgia, fatigue, anorexia, nausea and weight loss. This may be confused with poor control of the primary disease process e.g.PMR.
Dr. David, Rheumatologist in Harley Street or Oxford can assist you with steroid management.