Steroids in the Treatment of Lupus
Robert S. Katz, M.D.
Presbyterian St. Lukes Medical Center
Associate Professor, Rush Medical College
Chicago, Illinois
Many of the symptoms of lupus result from inflammation in various tissues of the body. Cortisone manufactured naturally by the body’s adrenal glands and also made synthetically, has been found to have a marked anti-inflammatory effect.
Cortisone and its derivatives are steroids, the most effective anti-inflammatory drugs known. Their use can substantially reduce the swelling, warmth, tenderness and pain that is associated with inflammation.
While steroid dosage should be kept at the lowest effective level, steroids must not be stopped suddenly if they have been taken for more than four weeks. After that time, some shrinking of the adrenal glands will occur, and they may not produce enough cortisone if the synthetic steroids are discontinued abruptly. A slow reduction in the dosage of steroids allows the adrenal glands to regain their ability to manufacture natural cortisone.
Steroids produced by the outer part (cortex) of the adrenal gland are called “corticosteroids” Predinsone is the synthetic corticosteroid preparation most often used in the treatment of lupus. It comes in tablets of 1, 5, 10, and 20 milligrams (mg). It may be given as often as four times each day, as infrequently as once every other day, or at any frequency in between. Less than 10 mg per day is generally considered a low dose; 1 to 40 mg daily is a moderate dose; and 41 to 100 mg daily is a high dose. Steroids may also be given by intra-muscular (IM) injection or may injected directly into a joint.
Occasionally, very large doses of steroids may be given for a short period of time. This treatment, referred to as “pulse steroid treatment,” involves giving 1000 mg of methyl-prednisone intravenously each day for three days.
Prednisone is an extremely effective drug and may be necessary to control active lupus. Although many lupus patients do not need to stay on steroids continuously, those with severe disease or active and serious kidney lupus may require long-term steroid treatment.
There is usually prompt relief of most symptoms after initiation of treatment with corticosteroids. When pleurisy of pericarditis occur, small or moderate doses of steroids are helpful. Steroids can often be avoided completely in mild cases of lupus (i.e., those involving only the joints and skin).
In addition to prednisone, some other cortisone derivatives include hydrocortisone, methylprednisolone (Medrol) and dexamethasone (Decadron). Again, Predinsone and other steroids should not be stopped suddenly. Lupus patients should discuss the reasons for using steroids and other treatments alternatives which may be available with their physician.
Side Effects
Some of the more common side effects of steroids include changes in appearance, such as acne, development of a round or moon-shaped face and an increased appetite leading to weight gain. Steroids may also cause a redistribution of fat, leading to a swollen face and abdomen, but thin arms and legs. In some cases, the skin becomes more fragile, which leads to easy bruising.
Psychological side effects of steroids include irritability, agitation, euphoria or depression. Insomnia can also be a side effect. These changes in appearance and mood are often more apparent with high doses of steroids.
An increase in susceptibility to infections may occur with high doses of steroids. Prednisone may also aggravate diabetes, glaucoma, and high blood pressure, and often increases cholestrol and triglyceride levels in the blood. In children, steroids can suppress growth.
Side effects that may be caused by the long-term use of steroids include cataracts, muscle weakness, avascular necrosis of bone and osteoporosis. Avascular necrosis of bone, usually associated with high doses of prednisone of long periods of time, produces pain, an abnormal bone scan and an atypical X-ray appearance. It occurs most often in the hip, but it can also affect the shoulders, knees and other joints. Avascular necrosis of bone is quite painful and often requires either a core bone biopsy, electrical stimulation, or total surgical joint replacement for pain relief.
Steroids reduce calcium absorption through the gastrointestinal tract which may result in osteoporosis, or thinning of the bones. Osteoporosis can lead to bone fractures of the vertebrae, causing severe back pain. Giving calcium and other medications may help to prevent osteoporosis. There is also a relationship between steroids and premature arteriosclerosis, which is a narrowing of the blood vessels by fat (cholesterol) deposits. In general, there is a close relationship between the side effects of steroids and the dose and duration of their use. Thus, a high dose of steroids given over a long period of time is more likely to cause side effects than a lower dosage given over a shorter period of time.
Corticosteroids are extremely effective anti-inflammatory agents and can be very helpful in treating active lupus, despite their significant side effects. Treatment with steroids should always be kept at the lowest possible effective dose and should never be stopped suddenly. Hopefully, we will soon develop effective alternative therapies which will not be as toxic as steroids. The history of most therapies shows, however, that those which are extremely effective often are associated with side effects. This is certainly the case with steroids.