Introduction

Many of the symptoms of lupus result from inflammation in various tissues of the body. Cortisone, a steroid manufactured naturally by the body's adrenal glands, has been found to have a distinct anti-inflammatory effect.

Cortisone medications made synthetically are among the most effective anti-inflammatory drugs known. Although these drugs can cause undesirable side effects, their use can substantially reduce the symptoms associated with inflammation, such as:

- swelling
- warmth
- tenderness
- pain

Corticosteroids

Steroids produced by the outer part (cortex) of the adrenal gland are called corticosteroids.

• Corticosteroids are different from the "anabolic steroids" that weightlifters and other athletes sometimes take illegally to increase strength.
• Corticosteroid treatment usually relieves most symptoms promptly.
• Small or moderate doses of steroids are helpful in cases of:
  • pleurisy (inflammation around the lung)
  • pericarditis ( inflammation around the heart)
• Steroids can often be avoided completely in mild cases of lupus (i.e., those involving only the joints and skin).
• People with lupus should discuss with their physician the reasons for using steroids and other treatment alternatives which may be available.

Prednisone

Steroids produced by the outer part (cortex) of the adrenal gland are called corticosteroids . Corticosteroids are different from the “anabolic steroids” that weightlifters and other athletes sometimes take illegally to increase strength. Prednisone is the synthetic corticosteroid preparation most often used in the treatment of lupus. It comes in tablets of 1, 5, 10, and 20 milligrams (mg). It may be given as often as four times each day, as infrequently as once every other day, or at any frequency in between. 10 mg per day or less is generally considered a low dose; 11 to 40 mg daily is a moderate dose; and 41 to 100 mg daily is a high dose.

Steroids may also be given by intra-muscular (IM) injection into the skin for discoid rashes, or may be injected directly into a joint. Occasionally, very large doses of steroids may be given for a short period of time. This treatment, referred to as pulse steroids , involves giving 1000 mg of methyl-prednisolone intravenously each day for three days.

Prednisone is an extremely effective drug and may be necessary to control active lupus. Those individuals with organ-threatening disease (i.e., heart, lung, brain, kidney, liver) usually need steroids in order to prevent loss of function in the organ. People who tolerate steroids poorly or do not respond optimally often benefit from the addition of steroid-sparing or immune suppressive drugs.

Corticosteroid treatment usually relieves most symptoms promptly. When pleurisy (inflammation around the lung) or pericarditis ( inflammation around the heart) occur, small or moderate doses of steroids are helpful. Steroids can often be avoided completely in mild cases of lupus (i.e., those involving only the joints and skin).

In addition to prednisone, some other cortisone derivatives include hydrocortisone , methylprednisolone (Medrol), and dexamethasone (Decadron). People with lupus should discuss the reasons for using steroids and other treatment alternatives which may be available with their physician.

Side Effects

Some of the more common side effects of steroids include changes in appearance such as acne, development of a round or moon-shaped face, and an increased appetite leading to weight gain. Steroids may also cause a redistribution of fat, leading to a swollen face and abdomen, but thin arms and legs. The skin becomes more fragile, which leads to easy bruising.

Psychological side effects of steroids include irritability, agitation, euphoria or depression. Insomnia can also be a side effect. These changes in appearance and mood are more apparent with high doses of steroids.

An increase in susceptibility to infections may occur with high doses of steroids. Prednisone may also aggravate diabetes, glaucoma, and high blood pressure, and often increases cholesterol and triglyceride levels in the blood. Steroids also can suppress growth in children. Steroids do not cause cancer.

Side Effects From Steroid Use

As mentioned before, there are side effects associated with steroid medications, although changes in appearance and mood are more apparent with high doses of steroids. However, steroids do not cause cancer.

Some of the more common side effects are:

1. Changes in appearance
   • acne
   • development of a round or moon-shaped face
   • weight gain due to increased appetite
   • a redistribution of fat, leading to a swollen face and abdomen, but thin arms and legs
   • the skin becoming more fragile, which leads to easy bruising.
2. Psychological problems
   • irritability
   • agitation
   • euphoria or depression
   • insomnia.
3. An increase in susceptibility to infections may occur with high doses of steroids.
4. Prednisone may aggravate:
   • diabetes
   • glaucoma
   • high blood pressure
5. Prednisone often increases levels of:
   • cholesterol
   • triglycerides.
6. Steroids also can suppress growth in children.

Side Effects From Long-Term Use Of Steroids

Side effects that may be caused by the long-term use of steroids include avascular necrosis of bone, osteoporosis, cataracts, and muscle weakness.

Avascular necrosis of bone , usually associated with high doses of prednisone taken over long periods of time, produces pain, an abnormal bone scan, and an atypical X-ray appearance. It occurs most often in the hip, but it can also affect the shoulders, knees, and other joints. Avascular necrosis of bone is quite painful. Relief from pain often requires either a core bone biopsy or total surgical joint replacement.

Steroids cause osteoporosis , or thinning of the bones. Osteoporosis can lead to bone fractures, especially compression fractures of the vertebrae with severe back pain. Calcium and Vitamin D, hormones, calcitonin, nasal spray, bisphosphonates (Actonel, Fosamax) , parathyroid hormone (Forteo), or other medications may help to prevent osteoporosis.

There is also a relationship between steroids and premature arteriosclerosis , which is a narrowing of the blood vessels by fat (cholesterol) deposits.

In general, there is a close relationship between the side effects of steroids and the dose and duration of their use. Thus, a high dose of steroids given over a long period of time is more likely to cause side effects than a lower dosage given over a shorter period of time.

Steroid Dose And Usage

In general, there is a close relationship between the side effects of steroids and the dose and duration of their use. Thus, a high dose of steroids given over a long period of time is more likely to cause side effects than a lower dosage given over a shorter period of time.

Dose	Milligrams
Low	Less than 10 mg daily
Moderate	11 to 40 mg daily
High	41 to 100 mg daily

While steroid dosage should be kept at the lowest effective level, steroids must not be stopped suddenly if they have been taken for more than four weeks. After that time, some shrinking of the adrenal glands will occur, and they may not produce enough cortisone if the synthetic steroids are discontinued abruptly. A slow reduction in the dosage of steroids allows the adrenal glands to regain their ability to manufacture natural cortisone.

Conclusion

• Corticosteroids are extremely effective anti-inflammatory agents and can be very helpful in treating active lupus.
• Treatment with steroids should always be kept at the lowest possible effective dose and should never be stoppped suddenly.
• The hope is that effective alternative therapies will soon be developed which will not be as toxic as steroids.
• The history of most therapies shows, however, that those which are extremely effective often are associated with side effects. This is certainly the case with steroids.

Related Information

On this web site
Antimalarials
NSAIDs
Immunesuppressants

On the Internet
Medline Plus Health Information: Drug Information
MedlinePlus Health Information: About Your Medicines