Dr Kevin Yuen explains how steroid use affects your health in conversation with Dr Suganthi Kumaran.
What are steroids?
Steroids are man-made drugs that closely resemble cortisol, a hormone that the adrenal glands produce naturally. Steroids are extensively used in almost every sub-specialty of medicine and they work by decreasing inflammation and reducing the activity of the immune system. Inflammation is a process in which the body’s white blood cells and chemicals can protect against infection and foreign substances such as bacteria and viruses.
In certain diseases, however, the body’s defence system (immune system) doesn’t function properly. This might cause inflammation to work against the body’s tissues and cause damage. Steroids reduce the production of chemicals that cause inflammation. This helps to keep tissue damage as low as possible. Steroids also reduce the activity of the immune system by affecting the way white blood cells work.
Which are the commonly prescribed steroids?
Commonly prescribed steroids include hydrocortisone, prednisone, prednisolone, betamethasone, deflazacort, methylprednisolone, dexamethasone and fludrocortisone. Prednisone is the most commonly prescribed type of steroid.
How is steroid therapy administered?
Steroid therapy can be administered in a variety of ways, i.e. as a pill (orally) or delivering directly into a vein (intravenously) or via muscle (intramuscularly) or joint injections or skin creams or eye drops or ear drops. When given orally, intravenously and intramuscularly, the steroids can circulate through the bloodstream to various body sites and this usually aggravates the side-effects.
What illnesses are treated with steroids?
Steroids are used to treat a large number of medical conditions, including inflammatory bowel diseases (e.g. Crohn’s disease, ulcerative colitis), autoimmune diseases (e.g. multiple sclerosis, autoimmune hepatitis), and joint and muscle diseases (e.g. rheumatoid arthritis, systemic lupus erythematosus, polymyalgia rheumatica), allergies, lung diseases (e.g. asthma, chronic obstructive airways diseases), chemotherapy for some types of cancer and brain tumours, to reduce brain swelling and can be used as replacement treatment for people who have stopped making their own steroids (e.g. in Addison’s disease).
How does steroid therapy affect people with Diabetes?
The effect of steroids on glucose metabolism is complicated and is likely to result in the impairment of several pathways including causing pancreatic beta-cell dysfunction (impairing beta-cell sensitivity to glucose and ability to release insulin when glucose levels rise), promoting insulin resistance in muscles, fat and liver cells and causing breakdown of lipids into glycerol and fatty acids that worsen insulin resistance. In people with Diabetes, this effect is markedly pronounced, thus causing blood sugar levels to rise even higher.
What are the short-term side effects of steroid use?
Even short-term (i.e., less than one month) use of steroids can increase the risk of high blood pressure and raise the pressure on the eyes (called glaucoma), especially in people who are already at risk for these diseases. Steroids increase fluid levels in the body and blood vessels and affect the size of blood vessels through anti-inflammatory actions. Both of these effects contribute to the risk of high blood pressure and glaucoma.
The increase in fluid retention can also cause leg oedema, bloating and increased fat retention, especially in the stomach, neck and facial areas. Combined with the added side effect of increased appetite, both of these effects can result in increased weight gain and the development of Diabetes. Steroid use can also cause difficulty in sleeping, energy level changes (either reduced energy or hyperactivity) and mood swings.
What are the long-term side effects of steroid use?
Long-term use of steroids can cause stomach ulcers/gastrointestinal bleeding, bone thinning leading to osteoporosis, increased risk of blood clots leading to embolism, strokes and heart attacks, an increased risk of infections, thin skin, easy bruising, cataract, menstrual irregularities in women, growth suppression in children, slower healing of wounds, acne, hair loss, round face, stretch marks, psychosis, buffalo hump and muscle weakness.
Can steroids be discontinued abruptly?
Generally steroids cannot be stopped abruptly, especially if the doses used are larger doses over seven days or smaller doses for more than 14 days, as this can lead to the suppression of adrenal cortisol production. Tapering the drug is preferred as this gives the adrenal glands time to return to their normal patterns of cortisol secretion and prevent withdrawal symptoms and signs (e.g., weakness, fatigue, poor appetite, nausea, vomiting, light-headedness and abdominal pain), which can be life-threatening.
However, tapering may not completely prevent withdrawal symptoms and may be due to several factors, including a true physiological dependence on steroids. In such circumstances, the steroid tapering needs to be performed very gently and can take weeks, months and even years in severe cases, before the drug can be completely stopped.
Is insulin required to treat steroid-related Diabetes?
In most cases, insulin in the form of intermediate or long-acting is required to treat the high blood sugars. If the blood sugars are particularly high after meals, sometimes short-acting insulin therapy can also be added. On the contrary, in rare cases, short-acting insulin secreting tablets (e.g. netaglinide) may be used in patients with mild elevations of blood sugars after meals, normal fasting and pre-meal blood sugars.
Can topical steroid treatment cause steroid excess and its related side effects?
In most cases, no, but if the doses of topical steroids used are high and over a prolonged period of time, then yes, excess steroids can cause associated side effects. These side effects can include burning or stinging of the skin, worsening of a pre-existing skin infection, folliculitis, thinning of the skin, stretch marks, and acne and skin redness, particularly on the face. Systemic side effects are rare with topical steroids and usually occur only when they are not applied as instructed.
What you should know about steroid use?
The person should inform his/her healthcare provider who is prescribing steroids that he/she has underlying Diabetes, as it may prompt the use of other medications instead of steroids. But if that is not an option, the patient needs to discuss with his/her diabetologist to develop a plan of action.
This includes checking blood sugars more often (e.g. 4-6 times a day including before and 2 hours after meals), if on insulin a likely need to increase the dose (if taking prednisone in the morning, for example, to increase the morning intermediate-acting insulin by up to 20-30 per cent, as guided by the blood sugar levels), if only on pills likely a need to increase the dose or add another type of pill or possibly even add insulin temporarily, but this is highly dependent on the level of blood sugars.
To call the healthcare provider or Diabetes educator if the blood sugar levels continue to rise while on steroids and that the current Diabetes medication is not effective to bring the blood sugars down and to carry treatment at all times in case of insulin-induced low blood sugars (e.g. glucose tablets, juice, candy) that may occur suddenly.
The patient needs to be especially careful with maintaining his/her eating plan while on steroids, because eating a lot of carbohydrates or large portions (which can be the case as steroids can increase the appetite) will raise blood sugars much faster.
When the steroid dose is being tapered down, the patient needs to be aware that his/her Diabetes drug doses will likely need to be tapered accordingly and checking the blood sugars regularly is important to tailor the lowering of Diabetes drug doses during this period.
If the patient receives a steroid injection, the patient needs to be aware that the effect on the blood sugars may hang around for several weeks or even months. Steroid inhalers and creams usually do not raise blood sugar levels much and patients can be reassured.