Glucocorticoids, one of the groups of adrenal steroids, are used to treat asthma, bronchitis, allergies and other breathing problems; conditions that produce inflammation, such as arthritis and other joint and muscle disorders; skin conditions; and certain cancers, hormonal disorders and infections. For several of these conditions (e.g., asthma), these drugs can be extremely effective and even lifesaving. For others (e.g., allergies, arthritis), they are best not used as initial therapy and should instead be saved for more severe cases. Unfortunately, some physicians still prescribe oral glucocorticoids too widely. For example, some pediatricians use the drugs for a variety of ear, nose and throat conditions, despite the absence of evidence to support most such uses. Similarly, glucocorticoids can be effective in the treatment of rheumatoid arthritis, but their place in therapy remains controversial; other drugs should be used first.
Drugs taken by mouth (orally) are distributed throughout the body to areas that require treatment as well as to those that do not. Because the entire body is exposed to the drug’s action, there can be unnecessary adverse effects. For this reason, if the drug can be delivered directly to the site of action (e.g., eye, lung, skin), this is generally preferred. For similar reasons, the oral glucocorticoids should be used at the lowest effective dose and for the shortest duration possible. Rarely, patients taking glucocorticoids have experienced severe allergic (anaphylactic) reactions.
Corticosteroids can produce reversible suppression of the production of the hormones that help the body deal with stress and produce the “fight or flight” response. It is possible that after treatment, your body will not produce enough of these hormones right away.
Adverse effects from oral glucocorticoids can be minimized further by using alternate-day therapy. If you will be taking oral steroids on a long-term basis, ask your doctor about switching to alternate-day therapy. The body’s own glucocorticoids are released primarily in the early morning hours between 4:00 a.m. and 8:00 a.m., with very little being released in the evenings. These variations help to set your body’s clock and to establish sleep and waking cycles. Therefore, for the least disruption of your body’s natural rhythms, a single daily dose or an alternate-day dose should be taken in the morning prior to 8:00 a.m.
If you take an oral glucocorticoid every day or every other day, you will need one that stays in the body long enough. Adrenal steroids are divided into short-acting (e.g., hydrocortisone), intermediate-acting (e.g., methylprednisolone, prednisolone, prednisone), and long-acting (e.g., dexamethasone) glucocorticoids. For the conditions discussed in this chapter, intermediate-acting glucocorticoids will usually be the most appropriate choice,3 and prednisone is the one used most frequently.
Glucocorticoids suppress your immune system, lowering your defenses against disease and making you more vulnerable to infections. If you use these drugs for a long time, you increase your risk of getting bacterial, viral, parasitic and fungal infections. For this reason, avoid exposure to chicken pox and measles, in particular, if you are taking these drugs.
Glucocorticoids also can cause osteoporosis, even if used short-term or at low doses; fluid retention; and high blood pressure. These adverse effects are all more common in the elderly.
Glucocorticoid users also are more prone to gastrointestinal ulcers and psychiatric disturbances ranging from confusion to depression to psychosis. Cases of psychiatric and behavior disorders have been reported with inhaled, oral and injectable corticosteriod use. Glucocorticoids cause glaucoma and cataracts and slow wound healing. More commonly, they lead to weight gain and high blood sugar. The drugs should not be used if body-wide fungal or threadworm infection is present. Live virus vaccines (e.g., smallpox, oral polio virus) should not be administered to patients on high doses of glucocorticoids.
If you no longer need an oral glucocorticoid, your doctor should slowly reduce your dose over several weeks, unless you have only been taking the medication for less than a week. This is done to avoid a withdrawal syndrome (muscle and joint pain, fever) and, rarely, the absence of or reduction in adrenal function (due to previous suppression by the glucocorticoid), a serious medical problem.
On July 26, 2011, Public Citizen petitioned the Food and Drug Administration (FDA) to immediately require that the labels for all brands of prednisone and other glucocorticosteroids currently on the market in the U.S. be revised to include central serous chorioretinopathy as one of the ophthalmic adverse reactions reported with these medications if not already included. At present, a substantial proportion of the labels for these products (87 percent of labels that we reviewed) do not contain a warning about this potentially serious adverse reaction. Furthermore, the FDA should review the labels for all such medications and, as appropriate, require additional label changes to ensure that other important information regarding the use and safety of these medications is presented in a consistent manner across all labels.
In summary, these are useful drugs that are sometimes overprescribed but whose toxicity can be minimized if they are prescribed and taken properly.