Corticosteroids for Arthritis.

Last updated Thursday, December 30, 2004

About corticosteroids

What are they?

Corticosteroids are medications often used to treat arthritis and related conditions. These medications are widely used because of their overall effectiveness in reducing inflammation--the process that causes the joint pain, warmth, and swelling of arthritis and related conditions. Examples of corticosteroids include cortisone, prednisone, and methylprednisolone.

These medications are related to cortisol, which occurs naturally in the body. Cortisol is a hormone that controls many important body functions. You could not live without cortisol.

Corticosteroids are hormones, but they are not sex hormones. Sex hormones regulate sexual and reproductive function; corticosteroids do not. Doctors sometimes refer to corticosteroids as steroids. However, corticosteroids are not the same as anabolic steroid drugs that some athletes abuse.

Types of corticosteroids

Commonly used corticosteroid medications include:

This is a partial list and includes generic and brand names. Various corticosteroid syrups are available for children. Some corticosteroid preparations can be taken by injection.

Why corticosteroids?

Corticosteroids are used in arthritis for two reasons. First, they are anti-inflammatory; that is, they decrease inflammation. Many people who have rheumatic diseases experience a lot of inflammation, which is the process that causes the joint pain, warmth, and swelling of arthritis and related conditions. Inflammation can take place in the joints (rheumatoid arthritis), in the tendons (tendinitis), or in different organs at the same time (lupus).

In rheumatic diseases, one of the purposes of therapy is to stop inflammation and the damage it causes. Medications known as nonsteroidal anti-inflammatory drugs (NSAIDs) are often used to stop inflammation, but they may not be strong enough or may have too many side effects. When side effects from NSAIDs present a problem or inflammation is severe and threatens to cause serious damage, your doctor may prescribe corticosteroids to decrease inflammation.

Second, corticosteroids are immunosuppressive. This means that they reduce the activity of your immune system. A healthy immune system helps defend your body against bacteria, viruses, and cancer. However, sometimes the immune system goes out of control and starts attacking the tissues and organs of its own body. This is called autoimmunity, and most doctors feel that with diseases like rheumatoid arthritis, lupus, and vasculitis, the immune system has started attacking the body's own tissues and organs. In these diseases, corticosteroids help by decreasing the harmful autoimmune activity. However, they also decrease the body's helpful immune activity, which can increase susceptibility to infection and interfere with the healing process.

Dosage, benefits and risks

Arthritis affects people in different ways. For this reason, only your physician can determine how much medication you need to effectively treat the symptoms of your disease, and how much you can tolerate.

The benefits and the risks of corticosteroid treatment depend upon many factors, including:

• Dose. With some forms of arthritis, the treatment may start off with high doses. However, the treatment goal is to find the smallest possible dose that is still effective.
• Dosage form.
• Length of treatment. This can range from several days to many years.
• The specific disease being treated.
• Individual characteristics, such as your age, sex, physical activity, and other medications.

Corticosteroid dosage varies from disease to disease and from person to person.

The information provided here is general. Discuss your own situation with your doctor.

Types of arthritis

Corticosteroids are used to treat several forms of arthritis. Following are examples of some of the rheumatic diseases and conditions that respond to corticosteroid treatment:

• bursitis
• dermatomyositis
• fibromyalgia
• giant cell arteritis
• gout
• osteoarthritis
• polymyalgia rheumatica
• polymyositis
• pseudogout
• rheumatoid arthritis
• scleroderma
• systemic lupus erythematosus (lupus)
• tendinitis
• vasculitis

Administration

Doctors often prescribe corticosteroids in pill form, but there are other ways of taking them. For osteoarthritis and bursitis, corticosteroids often are injected directly into the joint or bursa. For other conditions, they are injected into a muscle or vein.

Doctors may use "pulse" corticosteroids--a procedure in which a very high dose of the medication is injected into a vein--e.g., when lupus seriously affects the kidneys, nervous system, or brain. Pulse corticosteroid treatment is a serious procedure that involves risks. It should only be used by specialists with appropriate training, preferably in a hospital.

Other conditions treated with corticosteroids

Skin conditions caused by certain forms of arthritis often are treated with corticosteroid creams applied directly to the spot. Certain eye conditions associated with arthritis are treated with corticosteroid eyedrops. Some allergies can be treated with nasal sprays. Unlike corticosteroid pills, corticosteroid creams, eyedrops, sprays, and injections into joints or bursae are less likely to cause side effects in other parts of the body.

Side effects

When taken as prescribed, corticosteroids can provide welcome relief from pain and inflammation. However, like any other medication, corticosteroids can cause side effects and serious medical problems if not carefully monitored by a doctor. It is very important to understand the differences between safe, proper use and improper use of these powerful drugs.

Most side effects are predictable and related to the dose. Some side effects occur in almost anyone who takes them. Other side effects are unpredictable; they may or may not occur.

Dosage and side effects

The following table is an example of how the risk increases as the dosage for the corticosteroid prednisone increases.

Very common side effects

• Weight gain. At first, most of the weight is water retention only, but as time goes by, corticosteroids also may increase your body fat. Corticosteroids also will increase your appetite. Anyone with a history of heart trouble or swelling in the legs should consult his or her doctor, since corticosteroids could affect such conditions.
• Mood swings. Some people find that corticosteroids make them feel more positive and uplifted while others feel sad, anxious, or depressed. Nervousness may occur, and difficulty in sleeping is common, especially if a dose is taken later in the day. People with a history of serious mental health problems should consult their doctor about how to deal with these risks.

Common side effects

In people who take corticosteroids continuously for more than a few weeks:

• Mild weakness in the muscles of arms or legs
• Blurred vision
• Hair growth: both thinning and excessive growth
• Easy bruising of the skin
• Slow healing of cuts and wounds
• Acne
• Round face
• Slowed growth in children and adolescents
• Osteoporosis (loss of bone calcium), especially in women, people with chronic kidney disease, those with a history of osteoporosis in the family, people who smoke, and people who are not physically active

Occasional side effects

In people who take corticosteroids for weeks to months, especially at moderate to high doses:

• High blood pressure
• Elevated blood sugar
• Red or purple stretch marks on the skin
• Stomach irritation or stomach ulcers, especially when also taking aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs)

Corticosteroids can make high blood pressure, diabetes, blood sugar problems, or ulcers suddenly worse. If you have had any of these conditions and need to take corticosteroids, it is very important to consult your doctor.

Less common side effects

In people whose corticosteroid use is moderate or prolonged:

• Blurred vision from cataracts
• Glaucoma
• Fractures due to osteoporosis, most often in the hip and spine
• Osteonecrosis, a serious and painful condition that occurs most often in the hip or shoulder when the bone is deprived of circulation
• Severe weakness of the muscles (myopathy)
• Psychosis, which is a severe disturbance of thinking
• Serious infections due to suppression of the immune system

Minimizing side effects

Corticosteroid use is less likely to cause side effects when you take your medication as prescribed and practice healthy habits (exercise regularly, eat nutritious foods, get enough rest). Following is a list of suggestions to help minimize side effects that can result from corticosteroid use.

1. Take your corticosteroids and other medications exactly as prescribed. Do not increase, decrease, or stop your dosage unless specifically instructed to do so.
2. Unless told otherwise, take a once-a-day dosage of corticosteroids early in the morning. It is more effective and less harmful that way.
3. Visit your doctor frequently to prevent side effects or to detect them at an early stage.
4. Contact your doctor if you develop high fevers with chills or shakes, severe pain in a joint or bone, persistent blurred vision, or severe muscle weakness. Also contact your doctor if you notice drastic mood changes that affect your behavior.
5. Wear a medical identification tag because of the possibility of side effects. Ask your doctor about how to get one.
6. Make sure you eat a healthy diet. Limit foods that are high in fat and salt. Also make sure your diet provides enough calcium and vitamin D. Dairy products such as milk and yogurt are good sources of both nutrients. As an option you can take calcium and vitamin D supplements. Your doctor can recommend the most suitable sources and the proper dose.
7. Exercise to maintain healthy bones and muscles. While it may seem harder to exercise when you're on steroids because of weight gain or muscle weakness, it's worth doing. Try a steady routine of walking, biking, or hiking three or four times a week, without overdoing it. A physical therapist or your doctor should prescribe an exercise program for you.

Pregnancy

In spite of the many possible side effects, corticosteroids, especially prednisone, can be used with relative safety during pregnancy. If you see different doctors for your rheumatic disease and for your pregnancy, both need to be involved in the decision of whether or not to use corticosteroids. If you are taking corticosteroids and planning a pregnancy, be sure to discuss this with your doctor. If you are taking corticosteroids and are pregnant, don't stop the medications suddenly--you must see your doctor and discuss this first. Since corticosteroids get into breast milk, nursing babies may experience side effects just like adults do, except more so. Discuss the alternatives with your doctor if you wish to nurse your baby.

Withdrawal symptoms

It may be difficult to lower your dosage of corticosteroids. If you have been on corticosteroids for more than just a few days, it can be dangerous to suddenly stop taking them.

Your body must have corticosteroids in case of stress, but the adrenal gland that produces them may not respond quickly enough. That's why your doctor usually will prescribe a "tapering schedule" for you, which is a gradual dose reduction. Be sure to follow your doctor's advice on how to do this.

Anyone who has taken corticosteroids for a couple of weeks or months will experience some discomfort when going through a dose reduction period. This "steroid withdrawal syndrome" may involve aching in the muscles, bones, and joints; nausea; weight loss; headache; and/or fever. Fortunately, the symptoms usually are not very severe, and they don't last more than a couple of weeks at the most. If your corticosteroids are being tapered and you develop symptoms, check with your doctor to make sure it is not the disease flaring up.

Reducing withdrawal symptoms

Sometimes, when you have been on corticosteroids for a while, your doctor may prescribe an "alternate-day" schedule. This means you take a higher dose one day, then a lower dose or none the next day, then the higher dose the third day, and so on. The regimen is altered so your body can function with less corticosteroids on low-dose days while the overall total dose (over two days) will keep your disease under control. Writing the dosage schedule on your calendar will help you remember it.

Your doctor may prescribe a "steroid-sparing agent" if your disease flares when corticosteroids are tapered. A steroid-sparing agent refers to another medication that can help keep the disease under control while corticosteroids are being tapered. It usually is an immunosuppressive drug. A steroid-sparing agent might be safer for long-term medication use than corticosteroids. You still will need to taper the corticosteroids slowly, though. The most commonly used steroid-sparing agents are methotrexate (Rheumatrex), azathioprine (Imuran), and hydroxychloroquine (Plaquenil). If you only have muscle or joint symptoms while tapering, nonsteroidal anti-inflammatory drugs (NSAIDs) may be used to control your symptoms.

Post-corticosteroid warnings

If you have been on corticosteroids for more than a few months, and now you are off, be sure to mention this to your doctors for the next year. This is especially important if you become very ill, require surgery for any reason, or need invasive diagnostic tests. In such instances you may be given a brief course of corticosteroids because your body may be making less than what would be required under those stressful circumstances.

Recent findings

Corticosteroids have been around for a long time, but research is still needed to improve the treatment of various diseases.

In recent years, new corticosteroids have been developed that may be safer than prednisone. However, they still are experimental and not available for general use.

Credits

The Arthritis Foundation and the University of Washington Department of Orthopaedics do not endorse any brand name or generic name medication listed here.

Some of this material may also be available in an Arthritis Foundation brochure. Contact the Washington/Alaska Chapter Helpline: (800) 542-0295. If dialing from outside of WA and AK, contact the National Helpline: (800) 283-7800.

Adapted from the pamphlet originally prepared for the Arthritis Foundation by James L. McGuire, MD, and Ronald F. Van Vollenhoven, MD, PhD. This material is protected by copyright.