Steroids are no doubt one of the most widely used medicines, next to OTC preparations and almost as commonly used as antibiotics for common ailments as well as in life-threatening conditions such as hospital acquired infections, in critically ill patients or as immunosuppressant in organ transplant patients as well as in common inflammatory conditions and in rheumatic patients. Corticosteroids are commonly referred to as “steroids” and they differ from anabolic steroids (male hormone-related steroid compounds), that some athletes abuse.

Corticosteroids are actually synthetic and semi-synthetic drugs that closely resemble a natural hormone cortisol in human body. This hormone “cortisol” is naturally produced by adrenal glands.

Steroidal drugs are synthetic and semi-synthetic analogues of this natural hormone “cortisol”, that is, they mimic the action of this natural hormone because cortisol has diverse functions. Cortisol is a glucocorticoid, that is, its main role is in the synthesis of glucose along with other diverse functions. The main role of this natural hormone in the body is to:

  1. Synthesize glucose (gluconeogenesis)
  2. Increase resistance to stress
  3. Have anti-inflammatory action
  4. Decrease the ability of body to fight infections

Steroidal Drugs Mimic These Actions Of This Natural Hormone, i.e.

  1. They provide energy in the form of glucose
  2. Help combat stressful conditions
  3. Used to counteract inflammation
  4. Weaken the immune system

The last action is a side-effect due to overdose of the natural hormone cortisol and of the steroidal drugs and is a serious adverse effect in case of abuse or overdose of these drugs.

The common drugs that are analogues of cortisol, that are frequently employed in clinical practices include:

  1. Short acting (1-12 hours): Hydrocortisone, Cortisone
  2. Intermediate acting (12-36 hours): prednisone, prednisolone, methyl prednisolone, triamcinolone
  3. Long acting (36-55 hours): Betamethasone, Dexamethasone

How to Administer

Steroids can be administered either locally to a precise place where a problem exists, or systemically, which means directly into the circulatory system or blood.

Local steroid treatments are administered for conditions such as ear drops, eye drops, joint injections and skin creams. For systemic steroid treatment, the medicines are commonly administered parenteral, meaning via injectable; either administered intravenously, that is, directly injected into a vein or intramuscularly (by injecting the drug into the muscles). Systemic steroids circulate through the bloodstream to various body sites.

Since, steroids are potent medicines, meaning less amount produces intense effects, in order to avoid severity of side effects, they are preferably prescribed for local ailments rather systemic which requires clinical monitoring.

Clinical Use Of Steroids

Inflammation is basically a defensive mechanism of the body when an injury or trauma occurs, but this defensive process is associated with three cardinal symptoms; mainly redness, pain and swelling and, since, these symptoms are painful, so in order to subside pain and swelling, the anti-inflammatory agents are given. The inflammatory mediators are released at the site of injury or trauma and invade and destroy any foreign agent but the excess of these inflammatory mediators can result in the destruction of body’s own cells and tissues, so in order to avoid such condition, anti-inflammatory agents, one of which are steroids, are administered. This helps keep tissue damage as low as possible

Steroids are prescribed for a number of conditions such as:

  • Gout
  • Rheumatoid Arthritis
  • Osteoarthritis
  • Bronchial Asthma
  • Allergic Rhinitis
  • Chronic Obstructive Pulmonary Disease
  • Tonsillitis
  • Acceleration Of Lung Maturation
  • Diagnose and Differentiate Cushing’s Syndrome
  • Addison Disease
  • Inflammatory Skin Conditions (pruritus, psoriasis, systemic lupus erythematous)
  • As Immunosuppressants, that is, to suppress the activity of over stimulated Immune System as happens in inflammatory conditions
  • In certain Cancer treatments
  • In Organ Transplant Surgeries( e.g. of kidneys or liver)
  • Systemic Vasculitis (inflammation of blood vessels)
  • Myositis (inflammation of muscle)

How Does Steroids Help In Critical Conditions

Steroids are considered organ-saving drugs in certain critical conditions when inflammation threatens to damage critical body organs. For instance, in patients suffering from lupus or vasculitis (inflammation of blood vessels), steroids may prevent the worsening of kidney inflammation, which could lead to kidney failure. By administering steroidal therapy, the need for kidney dialysis or transplantation might be eliminated.

Patients of rheumatoid arthritis can benefit from low doses of steroids, providing significant relief from pain and stiffness of joints. Severe flare-up of arthritis is also benefitted by the short-term use of higher doses of steroids, helping a person to recover as soon as possible.

Side Effects Due To Steroid Therapy

Just as steroid medications have diverse effects, so are their side-effects. This class of medication has varying side-effects on different systems of the body. Since, steroids are potent medicines, so they should be used in minute amounts and for shortest possible time. The topical medicines should not be used for more than 3 days a week and oral medicines should not be used for more than 3 weeks without consultation with a health practitioner and benefits should outweigh the risks. The intensity or severity of side effects depends on a number of side effects; for example:

  • On the duration or length of treatment: The longer you use these medications; the more profound the adverse effects.
  • The dose: It plays a critical role in adverse effects. The higher the dose the more susceptibility and severity of adverse effects.
  • The age: Children and elderly are more prone or vulnerable to adverse effects.
  • The dosage form: Whether you are taking a tablet, inhaler or injection. Injections are administered in hospitals so frequency of adversities is less with this dosage form. Inhalers are usually mild but tablets and topical medications can cause serious side effects if used for longer periods of time.

Inhaled Corticosteroids (ICS)

Inhaled corticosteroids are the preferred treatment for long-term control of mild persistent, moderate persistent, or severe persistent asthma symptoms in children, teens, and adults.

  • For Asthma

Inhaled corticosteroids (ICS) are the drugs of choice in patients with any degree of persistent asthma (mild, moderate and severe). Severe persistent asthma may require the addition of a short course of oral glucocorticoid treatment dexamethasone, methylprednisolone, and betamethasone). No other medications are as effective as ICS in the long-term control of asthma in children and adults. If appropriately prescribed and used, ICS therapy may reduce or eliminate the need for oral glucocorticoids in patients with severe asthma.

  • For Allergic Rhinitis

Corticosteroids such as beclomethasone, budesonide, fluticasone, flunisolide, ciclesonide, mometasone and triamcinolone, are effective when administered as nasal sprays (Note: Patients should be counseled not to deeply inhale while administering these drugs because the target tissue is in the nose, not in the lungs or throat, in order to avoid systemic absorption, that is, absorption of drug in the blood).

Oral Corticosteroids

Oral glucocorticoids or corticosteroid drugs are used in rheumatoid arthritis, in certain cancers such as acute lymphocytic leukemia and in the treatment of both Hodgkin and non-Hodgkin lymphomas (oral prednisone is used in rheumatoid arthritis and cancer) as immunosuppressants in organ transplant rejections (prednisone, methyl prednisolone) and as anti-emetic (to control vomiting) in chemotherapy.

Systemic Corticosteroids (via intravenous or intramuscular route)

Patients with severe exacerbation of asthma may require intravenous administration of methylprednisolone, as well as in cancers and before or after transplant surgery and for lung maturation in neonates, administered to mothers 48 hours prior to birth, followed by a second dose 24 hours before delivery.

Adverse Effects

Oral or parenteral glucocorticoids have a variety of potentially serious side effects, whereas inhaled corticosteroids, particularly if used with spacer, have few side effects. The most common side effects are:

  1. Decreased growth in children
  2. Glaucoma
  3. Osteoporosis
  4. Increased risk of infection
  5. Impaired wound healing
  6. Increased appetite
  7. Centripetal fat distribution
  8. Emotional disturbances
  9. Peptic ulcer
  10. Increased blood pressure
  11. Swelling of limbs
  12. Decreased potassium levels ( risk of arrhythmias in heart)

Steroids Prescribed In ICU Linked To Delirium

Critically ill patients, admitted in hospital’s intensive care unit (ICU), receiving steroids have marked chances of developing delirium. Although, minimizing the use of steroids could reduce delirium in the ICU, and it usually goes away after a few days, but studies have shown that delirium in the ICU has a long-term impact. The long-term negative impact is associated with worse functional recovery and cognitive impairments and the severity and magnitude is equivalent to moderate traumatic brain injury or mild Alzheimer’s disease.

Steroid Injection Linked To Increased Risk Of Bone Fractures

Back pain relief is often treated with epidural injections (epidural space of spinal cord) and patients receiving such treatment with an epidural steroid injection have marked risk of bone fractures in the spine. Researchers claim that the risk of fracture increases 29 percent with each steroid injection.

Steroid Injection Linked With Significant Bone Loss In Postmenopausal Women Treated For Back Pain

Women of postmenopausal age have high chances of bone fractures as they are now bereft of estrogen benefits (estrogen has multiple benefits on women health) because estrogen levels decline after menopause and have high risks for cardiovascular diseases and osteoporosis.

Studies have found that women who received epidural steroid injection for back pain relief, suffered from significant bone density loss in their hip. Bone density loss was six times greater after six months of treatment in such post-menopausal women, compared to the postmenopausal women who didn’t receive steroid injection.