What are steroids and how do they act?

Steroids are chemicals (hormones) that occur naturally in the body and help to maintain health and well-being. Steroid medicines are man-made, but similar to these natural hormones.

They decrease inflammation and, when given in doses higher than normally made by the body, they suppress the body’s immune system.

They block the DNA being made and block a chemical named histamine which is released during allergic reaction.

They are different from anabolic steroids, which are used by athletes and bodybuilders.

What are the different type of steroids?

Glucocorticoids - These are the most commonly used group of steroids

• Prednisolone

• Betamethasone

• Hydrocortisone

• Methylprednisolone

• Dexamethasone

• Deflazacort

Mineralocorticoids - This group is usually used for replacing steroids the body is not producing itself

• The common one used is fludrocortisone, which is available as tablets, dispersible tablets or solutions

Intravenous steroids -They are usually given directly into the vein in hospital and include hydrocortisone and methylprednisolone

For what conditions are oral steroids prescribed?

Oral steroids are used to treat a wide range of inflammatory and auto immune diseases

• Auto immune diseases, example systemic lupus erythematosus and pemphigus vulgaris

• Allergies including Severe allergy reactions

• Joint and muscle disease like Rheumatoid arthritis

• To prevent organ rejection after a transplant

• Asthma

• In inflammation affecting blood vessels, heart, bowel, kidneys

• Inflammatory bowel disease, example Crohn’s disease, and ulcerative colitis

• Some cancers, including leukaemia, lymphoma, and myeloma

How are oral steroids available?

Steroids are available as tablets, soluble tablets and liquids.

How much steroids administered?

• By mouth (Oral) It is the usual route

• By injection into muscle (intramuscular)

• By injection into the vein (IV infusion)

• By injection into a swollen joint (intra-articular)

When do I take steroids?

• Steroid should be taken with the first thing in the morning with milk on an empty stomach.

What is the dose of steroid to be given? For how long can steroids be given?

• The dose of the steroid will vary with individual steroids and the disease which they are prescribed for.

• For short courses, usually high dose is given to control the symptoms and is given daily for a few days or weeks and then stopped abruptly.

• If the steroid is required for more than three weeks, the dose will be tapered off gradually once the condition improves and then the treatment is gradually stopped.

• Sometimes steroids are needed lifelong as the symptoms return if they are stopped In some cases, steroids are to be taken every other day.

How long do steroids take to act?

With oral steroids, within a week one feels better, but it could take up to a month. In the case of iv steroids, it can take up to 10 days to feel better, after starting treatment. Few people do not respond to steroid, which is known as being steroid refractory.

What special dietary instructions should I follow?

A low salt, high potassium, high calcium diet is advisable. Supplemental calcium and vitamin D is usually prescribed with steroids.

Why is it necessary to reduce the dose of gradually before stopping steroids?

Human body normally produces steroids by itself which is required to maintain good health. When steroids are being taken for a few weeks or more, the body may reduce or stop making its own steroids, hence if the steroids are stopped suddenly, the body does not have any steroids which can lead to various withdrawal symptoms that occurs until the body resumes making natural steroids. The withdrawal symptoms can be serious and life threatening and include

• Weakness

• Tiredness

• Feeling sick

• Being sick

• Diarrhoea

• Abdominal pain

• low blood sugar

• low blood pressure which causes dizziness, fainting or collapse.

• The body gradually resumes as natural production of steroids if the dose is gradually reduced and the withdrawal symptoms do not occur. 

Do the steroids cause any side-effects?

Side-effects do not occur with a short cause of steroids. Side-effects are more likely for long cause of steroids for more than 2 to 3 months are taken or when short courses are taken repeatedly. The higher the dose, the greater is the risk of side-effects, hence the lowest possible dose of dose which controls the symptom is prescribed when steroids are needed long term.  A common treatment plan is to start with a high dose to control symptoms and then the dose slowly reduced to lower daily dose that keeps the symptoms away. Length of treatment can vary depending on the disease.

What are the side effects?

• Elevated eye pressure (glaucoma) if not diagnosed early can lead to lower vision

• Fluid retention, leading to swelling in the legs

• High blood pressure or hypertension

• Mood swings

• Weight gain on the face, neck and abdomen

• Cataracts

• High blood, sugar or diabetes

• Increase risk of infections like chickenpox, reactivation of tuberculosis

• Osteoporosis - Thinning of bones and fractures

• Poor healing after injury

• Thinning of skin or easy brusing and stretch marks

• Difficulty in sleep insomnia

• Muscle weakness, especially of the thigh muscles, causing difficulty in getting up

• Duodenal and stomach ulcers, causing indigestion and abdominal pain

• Thrush in the mouth (fungal Infection)

• Indigestion and heartburn mood

• Behavioural changes

• Weight gain

• Hip or shoulder avascular necrosis

• Pain or infection in the joint may occur if steroids are injected in the joint

Who cannot take oral steroids?

Steroids cannot be given to some patients, for example in patients who have serious infections, as steroid suppress the immune system.
Steroids should be used in caution in the following people

• In whom the liver is not functioning well

• Having history of mental health problems

• Having open wounds, as steroids can interfere with healing

• Having a history of stomach or duodenal ulcers

• Having thinning of bones

• Having cataract

• Having certain heart conditions like heart attack, heart failure, high blood  pressure

• Having diabetes

• Having epilepsy

• Are pregnant - if the steroids are taken within the first 12 weeks of pregnancy, there is a doubtful risk that the baby could be born with a Cleft lip or Cleft palate. A long course of steroids can affect the baby growth

• Breastfeeding : Breastfeeding should be done four hours after taking steroids. If high doses of steroids are being taken during breastfeeding,baby may need monitoring

• Having severe depression

• Having allergy to steroid or any of its components

Can any other medicine be taken while taking steroids?

Many other medicines can interact with steroids i.e: steroid could affect how the other medication works, resulting in the other medicine being ineffective or having more side-effects. Sometimes the other medicine could affect the steroid. So doses must be adjusted accordingly so both medicines can be taken together.

Medicines that interact with steroids

• Warfarin and blood thinning medicines used to prevent blood clot

• Non-steroid anti-inflammatory drugs (NSAIDS) like ibubrufen and diclofenac. These when taken with steroids can cause stomach ulcers

• Live vaccines - They are usually not given for three months after high dose steroid drugs

• Anti Epilepsy drugs like carbamazepine, phenytoin, phenobarbital

• Diabetes drugs

• Bronchodilators like Salbutomol

• Digoxin

• Diuretics

• HIV drugs

• Antifungal drugs

• Some antibiotics

How to monitor when on Steroids?

Weight and BP have to be monitored as weight gain and high blood pressure are side effects of steroids. Bone density has to be monitored as steroid causes thinning of the bones. Eyes need to be monitored for cataract.

Can steroids be given during pregnancy?

• Steroids are safe for men and women wanting to conceive.

• Taking steroids during pregnancy is low risk to the baby, as a small amount of steroid make cross the placenta. Upto 40 mg of Prednisolone daily is considered safe for the baby.

• There is an increased risk of  Intra uterine growth retardation (IUGR - baby may grow more slowly) if the mother is on high dose steroids.

• There may be a doubtful risk of cleft lip and palate in babies born to mothers taking steroids during the first three months of pregnancy.

• If steroids are required during pregnancy, the lowest possible dose on the shortest possible time should be used

Can steroids be given during breastfeeding?

Very small amount of steroid may pass to the baby through breast milk. So it is usually considered safe to breastfeed while taking steroids.

Use of steroids and children and adolescence

Use of steroids can slow down normal growth of children and adolescents so dose  adjustment or treatment stoppage maybe done.

Steroid safety in elderly

Some of the steroid side effects can be more serious eg: brittle bones, diabetes, high BP, infection and thinning of skin. Caution should be exercised. 

Disclaimer: This article is only for general patient information and is not intended for self medication. There is no legal liability of IADVL arising out of any adverse consequence to the patient. Subsequent to its use for self treatment of the disease images adjust for the depiction of the condition and is not to be used for any other purpose.