Oral Steroids

Oral steroids, or Systemic corticosteroid, are orally ingested steroids used to treat skin conditions. These drugs help suppress the immune system to help with diseases like vitiligo, lupus, arthritis, and a plethora of other conditions.

 

What is a systemic corticosteroid?

A systemic steroid is a corticosteroid that is taken orally or administered intramuscularly. Systemic steroids are synthetic derivatives of cortisol, a natural steroid produced by the adrenal glands that has potent anti-inflammatory properties.

Glucocorticoids and cortisones are other names for systemic (cortico)steroids. They are as follows:

  • Prednisone
  • Prednisolone
  • Methylprednisolone
  • Beclomethasone
  • Betamethasone
  • Dexamethasone
  • Hydrocortisone
  • Triamcinolone

Prednisone and prednisolone are the most widely administered oral corticosteroids for inflammatory skin disorders and are interchangeable. Oral prednisone is the most widely given systemic steroid.

Fludrocortisone is mostly a mineralocorticoid with negligible anti-inflammatory properties.

How does a systemic steroid work?

Systemic steroids function similarly to natural cortisol. Natural cortisol has numerous physiological impacts, including the regulation of:

  • Protein, carbohydrate, lipid and nucleic acid metabolism
  • Inflammation and immune response
  • Distribution and excretion of water and solutes
  • Secretion of adrenocorticotrophic hormone (ACTH) from the pituitary gland.

What is the usual dose of prednisone?

To gain control of the skin problem, a greater dose of prednisone, such as 40–60 mg daily, is usually administered at first. The dose is lowered after 2–4 weeks.

When opposed to nighttime administration, prednisone is best administered as a single dose in the morning, which is hypothesized to lessen steroid-induced suppression of the pituitary-adrenal axis.

To minimize side effects, the maintenance dose should be kept as low as possible.

Steroid dose is commonly characterized as:

  • Low dose, eg < 10mg/day of prednisone
  • Medium dose, eg 10–20 mg/day of prednisone
  • High dose, eg > 20mg/day of prednisone, sometimes more than 100 mg/day

Short-term treatment is defined as treatment that lasts less than one month. When used for a few days or weeks to treat acute dermatitis, corticosteroids are relatively safe. Long-term treatment is defined as any treatment that lasts longer than three months and causes the majority of the negative side effects.

What are the side effects and risks of short-term systemic steroid?

Side effects are rarely serious if a systemic steroid has been prescribed for one month or less. The following problems may arise, particularly when higher doses are taken:

  • Sleep disturbance
  • Increased appetite
  • Weight gain
  • Increase in postprandial blood sugar
  • Psychological effects, including increased or decreased energy.

The following are uncommon but possibly dangerous side effects of a short course of corticosteroids:

  • Severe infection
  • Mania, psychosis, delirium, depression with suicidal intent
  • Heart failure
  • Peptic ulceration
  • Diabetes mellitus
  • Avascular necrosis of the hip.

The risk of a serious side effect increases with increasing dose.

What are the side effects and risks of long-term systemic steroid?

Almost everyone who takes a systemic steroid for more than a month experiences some side effects, which vary depending on daily dose and length of time on the drug. Infections, hypertension, diabetes, osteoporosis, avascular necrosis, myopathy, cataracts, and glaucoma are the main problems. The following list is incomplete.

Cutaneous adverse effects

Long-term systemic steroids can cause cutaneous side effects such as:

  • Bacterial infections: cellulitis, wound infection
  • Fungal infections: tinea, candida, pityriasis versicolor
  • Viral infections: herpes zoster
  • Skin thinning, purpura, fragility, telangiectasia and slow wound healing, especially in sun-damaged areas
  • Stretch marks (striae) under the arms and in the groin
  • Steroid acne
  • Hypertrichosis and hair loss.

Effects on body fat

  • Redistribution of body fat: moon face, buffalo hump, truncal obesity
  • Weight gain: increased appetite and food intake

Effects on the eye

  • Glaucoma
  • Posterior subcapsular cataracts; greater risk in children than adults
  • Eyelid oedema and exophthalmos
  • Central serous chorioretinopathy

Vascular disease

  • Hypertension
  • Ischaemic heart disease
  • Stroke and transient ischaemic attack (TIA)

Systemic steroids’ impact on atherosclerotic vascular disease could be attributed to a variety of metabolic alterations, including:

  • Hyperlipidaemia
  • Peripheral insulin resistance and hyperinsulinaemia.

Gastrointestinal tract

  • Acute pancreatitis
  • Dyspepsia, gastritis, peptic ulcers, and intestinal perforation, particularly in individuals on nonsteroidal anti-inflammatory medicines.
  • Fatty liver
  • Fluid balance
  • Sodium and fluid retention cause leg swelling and weight increase
  • Potassium loss causes general weakness

Reproductive system

  • Irregular menstruation
  • Hirsutism
  • Lowered fertility in both men and women
  • Possible fetal growth retardation in women taking prolonged courses of steroids during pregnancy
  • Breastfeeding can usually continue but infant should be monitored for adrenal suppression if the mother on > 40 mg prednisone daily

Musculoskeletal system

  • Bone fracture
  • Osteoporosis
  • Osteonecrosis, especially hip
  • Myopathy affecting shoulders and thighs
  • Tendon rupture
  • Growth restriction in children

Smokers, postmenopausal women, the elderly, those who are underweight or sedentary, and those who have diabetes or lung difficulties are all at risk for osteoporosis. With minimal trauma, osteoporosis can cause fractures of the spine, ribs, or hip joint. These occur in 10–20 percent of patients treated with more than 7.5 mg prednisone daily after the first year. Up to 50% of people taking long-term prednisone are expected to develop bone fractures. Even in persons with adequate bone density, vertebral fractures are more prevalent in those on steroids.

Nervous system

  • Psychological effects: mood changes, increased energy, excitement, euphoria, agitation
  • Less often: hypomania, psychosis, delirium, memory loss, depression, anxiety, personality change
  • Insomnia and sleep disturbance
  • Shakiness and tremor
  • Headaches

Metabolic effects

  • Transient or persistent diabetes in previously non-diabetic patients
  • Higher blood sugar levels in patients with diabetes mellitus
  • Cushing syndrome

Immune response

  • Raised neutrophil and total white cell count are usual on prednisone
  • Impaired innate and acquired immunity
  • Increased susceptibility to tuberculosis
  • Increased severity of measles, varicella
  • Reduced efficacy and increased risk of vaccines

Patients receiving less than 20 mg of prednisone daily should avoid live immunizations like polio or MMR (measles, mumps, rubella). Other routine immunizations, such as annual influenza vaccination, are safe and recommended.

Risks during intercurrent illness or surgery

Significant intercurrent sickness, trauma, or surgical procedure necessitates a temporary increase in corticosteroid dose, or, if the steroids have already been stopped, a temporary reintroduction of corticosteroid treatment for up to twelve months after the steroids have been stopped.

Patients who have taken less than 10 mg prednisone daily in the last three months and require a general anaesthetic should inform their anaesthetist so that intraoperative intravenous hydrocortisone can be given.

Effects of reducing the dose of systemic steroid

If you’ve only been on prednisone for one to two weeks, there’s no need to taper. To avoid acute adrenal insufficiency, steroids should be tapered off gradually after lengthier courses, especially if the medicine has been taken for several months or longer.

Prednisone reduction may cause the following side effects:

  • Fever
  • Hypotension
  • Tiredness
  • Headaches
  • Muscle and joint aches
  • Weight loss
  • Depression
  • Rhinitis
  • Conjunctivitis
  • Painful itchy skin nodules.

The suppression of the hypopituitary-pituitary-adrenal (HPA) axis can last for months or years after steroids are ceased.

Monitoring during steroid treatment

Regular monitoring during treatment with systemic steroid may include:

  • Blood pressure
  • Body weight
  • Blood sugar

Non-steroidal anti-inflammatory medicines (NSAIDs) and licorice should be avoided by prednisone patients.

Prevention of osteoporosis

Patients who have taken or are expected to take 7.5 mg or more of prednisone per day for three months or longer should consider getting a bone density scan. T-scores can be used to assess baseline fracture risk.

Current recommendations are:

  • Individuals with a femoral T-score of -2.5 should get bisphosphonate medication (alendronate, etidronate, or zoledronic acid). It cuts the chance of fracture in half.
  • Quitting smoking
  • A well-balanced diet with the goal of maintaining a healthy body weight
  • Alcohol consumption is kept to a minimum.
  • Weight-bearing exercise should be done on a regular basis.
  • Consider the dangers of falling and how to avoid them.

Because the risks of calcium, vitamin D, and estrogen outweigh the benefits, they are no longer advised for osteoporosis prevention.

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