CORTICOSTEROIDS


What are corticosteroids ?
Cortisone is a hormone secreted by the adrenal gland and is essential for normal body function. This was the first compound used to treat patients of rheumatoid arthritis with dramatic results. In fact this discovery was awarded a Noble Prize. The term corticosteroids (CS) includes cortisone and subsequent modifications in the parent substance to get more potent molecules (compounds).

Why are then corticosteroids not used in every patient ?
Unfortunately it was soon realised that corticosteroids when used in large doses or when given for a long time have many undesirable (side) effects e.g. weight gain, high B.P., diabetes, osteoporosis, cataract, glaucoma, thinning of skin, an increased susceptibility to infections and steroid dependence. This has cut down the use of corticosteroids to specific situations.

Which are the situations when corticosteroids can be used in RA ?
Corticosteroids are the most potent anti-inflammatory compounds known. As has been pointed out, it is the persistent inflammation that leads to disability, dysfunction and joint damage. Therefore in patients with very aggressive disease, until DMARDs (discussed in previous communication) start being effective, corticosteroids can help the patient to tide over this period (a kind of bridge, therefore also called “bridge therapy”). This period should not last for more than a few weeks. Used in this fashion, corticosteroids, in a way become effective DMARDs. As discussed in the last communication, for maximum benefit even corticosteroids must be used in the early stage of the disease to gain maximum benefit. Other situations are disease flares and non respective RA. Rare indications are patients with severe complications affecting eye, lungs, heart, nerves, blood vessels and skin.

What would be the dose of corticosteroids ?
Ideally the dose of corticosteroids should not be more than 5 – 7.5 mg/d of prednisolone. In situations such as involvement of eye, lung, blood vessels, etc much higher doses are required. In these cases other drugs like cyclophosphamide are combined with prednisolone. Such situations are however not very common. The principle is to use the lowest effective dose for as short a period as possible. Naturally, with very small doses, side effects are minimised, permitting longer therapy (if required).

Can cortisone be given as an injection ?
Yes, some rheumatologists, instead of daily oral dose prefer a monthly injection to achieve the same result. This is essentially a matter of perception.
Another, much more commonly used route is direct injection into the joint (IA) (or in affected tissues – bursae, tendon sheaths etc). IA injection is indicated when the disease is active in 1 – 2 joints only. This avoids increased doses of oral medications.

Are there any “rules” for IA steorids ?
Yes. At a time not more than 3 joints should be injected. The same joint should not be injected before a period of 3 months has elapsed. No joint should be injected more than 3 times in a year.

Why do we need to repeat IA corticosteroids ?
The reason is IA injection of corticosteroids does not control the joint inflammation permanently. In fact the duration of benefit is quite variable – from a week or two to many months.

Why not inject joints more frequently ?
Very frequent injections carry certain risks :
1.	Introducing infection
2.	Damaging the joint

How to prevent steroids side effects ?
The best way is to avoid corticosteroids or to use the minimum dose for the shortest possible period. Additionally following measures are advocated.
1.	Calcium and vitamin D supplements and exercises to avoid osteoporosis
2.	Diet control. Avoid weight gain
3.	Regular BP and blood sugar check up
4.	Watching / monitoring cholesterol and triglycerides Additionally we advocate isonex for one year to prevent the possibility of contracting TB if steroids are to be taken in high dosage and for a longer duration.

Common names of corticosteroids in use are
	Cortisone – rarely used
	Hydrocortisone – rarely used in rheumatology practice
	Prednisone / prednisolone – most commonly used preparation
	Triamcinolone – used for local injections
	Dexamethasone – useful but not the preferred compound
	Betamethasone – useful but not the preferred compound

Of these for oral use prednisolone is the most preferred compound.
It is essential to always discuss the details of steroid therapy with your doctor.

The message is “Do not be afraid of corticosteroids as they are useful and beneficial if used correctly and judiciously”.