Use of steroids: Balancing between benefit and risk

Follow dosing instructions to the letter and never stop abruptly, say the doctors

By suppressing the immune response and inflammation, steroids can keep a host of autoimmune diseases and allergic reactions from ravaging the body. They are the cornerstone of treatment for ailments like rheumatoid arthritis, asthma, ulcerative colitis, temporal arteritis, psoriasis and even bad cases of poison ivy.
But as with any powerful remedy, corticosteroids come with a downside: side effects that can sometimes be as serious as the ailments they are intended to treat.
Last week I was told about a friend with severe asthma who developed a rare complication that forced him to stop using the steroids that for decades had helped him breathe. He was losing his vision to steroid-caused macular degeneration. He found an alternative nondrug therapy, the Buteyko breathing method, that seems to have kept him well and steroid-free for many months.

But most people who depend on steroids are not so fortunate. For them, using the drugs year in and year out is a balancing act between benefit and risk. Knowing what those risks are and how they can be minimised can help people who depend on steroids to be alert to early warning signs of trouble and to take measures to counteract it -- in many cases before any unwanted effects occur.

Common side effects
The likelihood of serious side effects depends on how long steroids are used, how they are taken, what type of corticosteroid is prescribed and how high the dose must be to keep the ailment under control. They tend to cause fewer complications when applied to the skin, or when inhaled for days or weeks for an allergic reaction or asthma. Injected steroids or oral doses taken for months or years -- to treat rheumatoid arthritis, for example -- are far more likely to cause serious side effects, as are injected steroids.

So an over-the-counter steroid like hydrocortisone, applied to small areas of skin to relieve a mild case of dermatitis like poison ivy or eczema, is unlikely to have any untoward effects. But when injected repeatedly into a muscle or joint, corticosteroids can cause weakening and degenerative changes that limit their usefulness in treating chronic athletic or overuse injuries (to say nothing of their seemingly indiscriminate use by many professional athletes in recent years).
And if steroids are given intravenously, side effects may include insomnia, a metallic taste in the mouth, mood swings, nausea, rapid heartbeat and stomach irritation.
In most people, chronic use of inhaled steroids, considered medically essential to control most cases of asthma, has few if any adverse effects. Children may experience retarded growth, but studies have shown that they eventually catch up and achieve a normal height. The most common side effect, a fungal infection in the mouth called thrush, can be averted by using a spacer with the inhaler and rinsing the mouth with water afterward.

When corticosteroids are taken orally for less than three months, they are associated with temporary side effects like depression, an increased appetite, insomnia, mood swings and weight gain (partly from water retention).
Steroids taken orally for more than three months can have more profound and sometimes irreversible effects. Serious side effects are more likely when steroids are taken in high doses for a year or longer.
In addition to weight gain, side effects may include high blood pressure, deteriorating bones that can result in osteoporosis, diabetes, thinning of the skin, muscle weakness, moon face (caused by increased fat deposits, which may also occur in the stomach, chest and upper back), cataracts, glaucoma, ulcers, easy bruising, increased sweating, acne, arterial deposits that can lead to heart disease and, because of their effect on immunity, delayed healing of wounds and an increased risk of infection that can persist for a year or more after the medication is stopped.

Excess weight resulting from steroid use is normally lost within six months to a year after the drug is stopped and appetite returns to normal.

How to minimise them
When prescribed a corticosteroid, the most important thing is to follow dosing instructions to the letter. Use no more than is needed, and never abruptly stop steroids. The drugs suppress the function of your adrenal glands, which need time to recover. When the condition under treatment abates, gradually reduce the steroid dosage as instructed by your doctor.

In fact, for as long as a year afterward, you may need a "stress dose" of steroids to boost your immune response during extreme physical stress, as can result from surgery, an accident or a new serious illness.
Keep all immunizations up to date. Make sure to get a flu shot every year and, if on prolonged steroids, consider getting the pneumonia vaccine as well. Contact your doctor without delay at the first sign of what may be a serious infection, like high fever, productive cough, pain when urinating or large boils on the skin.

To minimize damage to the digestive tract, take the medication after meals or with an antacid. Let your doctor know if you develop persistent heartburn or black, tarry stools. To counter steroid-induced insomnia, take the drug early in the day.
An adequate intake of calcium and vitamin D through dairy products and supplements and regular weight-bearing exercise are vital to reducing the risk of osteoporosis. If you smoke, quit; and limit alcohol to a drink a day, if that. Reduce the risk of falls by using night lights and eliminating obstacles and scatter rugs.
Steroid-induced fluid retention that causes blood pressure to rise abnormally can be minimized by sticking to a low-sodium diet. Avoid salty foods and salted processed foods and snacks. Have regular blood-pressure checks and, if the rise is serious, ask the doctor about taking a diuretic. Periodic checks for a rise in blood sugar are also important. Reduce your risk of heart disease with a low-fat, low-cholesterol diet rich in vegetables and whole grains and regular aerobic exercise.

If you notice any vision problems while taking steroids, see an ophthalmologist without delay. The condition may be temporary, or it could be sight-threatening, as happened to my asthmatic friend. Rarely, damage to the hip joint called aseptic necrosis can result from long-term use of high doses of steroids. If you develop pain in the groin, a symptom of this condition, call your doctor.
The New York Times