Steroids
Overview: Commonly refers to the class of drugs known as glucocorticoids. This class is related to the natural hormone hydrocortisone, or cortisol.
Cortisol is essential for:
- Metabolism
- Bone formation
- Regulation of the immune system
Steroids are used for many different conditions like asthma, arthritis, rashes, and autoimmune diseases. These are different from anabolic steroids (synthetic steroids used for increasing muscle mass) because they are steroid hormones, a large class of fatty molecules the body makes from cholesterol. Other steroid hormones include estrogen, progesterone, and testosterone.
Steroids come in both oral and IV preparations, although most are given orally in pill form. In severe cases, doctors will administer them intravenously in the hospital. Some are even given as an enema, typically in colitis so that the steroid can work directly on the walls of the colon.
Enemas are liquid treatments that are inserted into the rectum to treat colitis. The liquid travels up the colon and treats inflammation in the rectum, sigmoid, descending, and even transverse colon. They are commonly used in conjunction with oral medications in IBD because this tends to speed up recovery. Mesalamine enemas can stain fabric, granite, marble, and vinyl so keep this in mind when administering.
Types:
- Systemic – work on the whole body, not just limited to the gut
- Can cause both benefit and side effects to the brain, bones, skin, muscles, and other organs
- Commonly prescribed: prednisone, methylprednisolone, hydrocortisone
- Non-systemic – effects are mostly limited to the gut
- Provide many of the same benefits as systemic steroids with lesser side effects to the other organs outside of the gut
- Commonly prescribed: Budesonide (Entocort), Budesonide MMX (Uceris)
- Budesonide is particularly effective in the last part of the small intestine (ileum) and first part of colon (ascending colon) – great for Crohn’s disease of these locations
- Budesonide MMX is a recently approved drug that works on the entire colon – especially helpful for colitis patients
How do they work?
- Main effect in IBD: Anti-inflammatory and immunosuppression
- Immunosuppressive drugs that decrease the immune system’s ability to fight infection and cause inflammation – we don’t want our immune system to attack things it shouldn’t, aka our gut
- Steroids keep the white blood cells (that cause inflammation) from sticking to the blood vessels, making it difficult for them to get where they want to go.
- You can think about the way the body attends to a cut or bee sting – it sends white blood cells there to help fight the wound so that it will heal faster. In this sense, acute inflammation is a good thing. But, in the case of IBD our bodies are attacking healthy tissue, thinking it’s an intruder or a wound so we want to slow down the inflammatory process to protect our gut. Steroids make sense here, because they also keep cells from releasing and responding to signals the cells use to recruit more cells to the inflamed area, which reduces systemic and prolonged inflammation.
When are they used?
- Short-term solution – 6-12 weeks with a taper is appropriate
- Tapering allows for a gradual weaning off of the drug to help prevent complications from abruptly stopping
- The body makes about 5-7 mg of prednisone daily in the adrenal glands and when you take steroids it sends the signal to your adrenal glands to stop steroid production, since there is enough being made already. Without a taper period, the body wouldn’t have enough time to produce more prednisone naturally and it could cause a withdrawal syndrome. Symptoms of withdrawal would be lightheadedness, dizziness, weakness, headaches, and feeling faint.
- To bring about remission when there is active inflammation in the bowel, typically used in a flare
- They should not be used in remission or maintenance because of the side effects they cause
- They are not helpful for preventing symptoms from returning in the long-term
Notes: When in a flare, your doctor may prescribe a steroid alongside other maintenance medications to reduce the inflammation. But, you can’t keep returning to steroids every time you flare. If you are receiving steroid prescriptions more than 2-3 times per year or becoming steroid dependent, a conversation with your doctor about stepping up therapy and using more potent drugs is appropriate. Sometimes even surgery is considered a better option than staying on steroids too long.
Side effects:
- Short term side effects, that increase the longer you are on them:
- Weight gain
- Facial swelling
- Mood swings
- Trouble sleeping
- Acne
- Increase in appetite
- High blood glucose
- Headache
- If on steroids longer than 6 weeks, additional symptoms you may experience include:
- Easy bruising of the skin
- Thinning of skin
- Osteoporosis (weakening of bones)
- Diabetes
- High blood pressure
- Cataracts
- Cushing’s syndrome
- Infections
- Muscle weakness
- Fatty Liver
- Depression
- Growth problems in children