Psoriatic Arthritis And Corticosteroids: 11 Questions To Ask Your Doctor
Its rare to prescribe corticosteroids for psoriatic arthritis, but sometimes a short course can relieve pain.
When youre suffering the pain of psoriatic arthritis, the first drug your doctor will typically suggest is a nonsteroidal anti-inflammatory drug , such as over-the-counter ibuprofen . But patients with particularly debilitating pain may instead be prescribed a short course of oral corticosteroids or a steroid injection.
Steroids work by reducing inflammation, which lessens pain and swelling. The most common oral steroid is prednisone, and the most common injectable steroid is cortisone. Triamcinolone and betamethasone are other steroids given orally or by injection. Another oral steroid, methylprednisolone, typically comes in a dose pack as Medrol.
Still, most rheumatologists hesitate to prescribe steroids unless they really seem necessary. Despite their effectiveness with rheumatoid arthritis, systemic steroids aren’t very effective for treating psoriatic arthritis, according to Vinod Chandran, MD, PhD, rheumatologist at Toronto Western Hospital and assistant professor at the University of Toronto in Ontario.
Given the side effects and the risk of severe worsening of psoriasis when the drug is tapered, we generally avoid systemic steroids in psoriatic arthritis, Dr. Chandran says.
Are Prednisone And Other Oral Steroids Safe For Asthma
While a two-week course or “short burst” of oral steroids like prednisone is relatively safe, itâs important to avoid steroids on a long-term basis as there are potential serious side effects. Taking supplemental calcium may help to prevent osteoporosis or thinning of the bones, which is one of the side effects of long-term steroid use.
Time To Reassess Messing Around With Steroids And Psoriasis
You don’t tug on Supermans capeYou don’t spit into the windYou don’t pull the mask off that old Lone RangerAnd you don’t mess around with Jim
If the late Jim Croce was a dermatologist, he would have added the lyric that you dont give systemic steroids to psoriatic patients because of the risk of inducing a pustular flare upon steroid withdrawal. Dermatology residents get indoctrinated with this dogma from day one is it a myth?
The prevalence of psoriasis is estimated at 3.2% of adults, with an increasing incidence in children. Appropriate treatment of psoriasis is based on disease severity in the context of comorbidities and concomitant medications. Even if systemic steroids are not used for psoriasis per se, their use may be indicated for co-existing maladies ranging from inflammatory bowel disease to poison ivy. Are we putting our psoriatic patients at risk by prescribing systemic steroids in these circumstances?
What we need to understand is why occasional psoriatic patients flare when exposed to steroids. Is it genetics? Comorbidities? Interactions with other medications?
Point to Remember: If systemic steroids are deemed necessary for patients with psoriasis or psoriatic arthritis, they should not be withheld based on the fear of inducing a pustular or erythrodermic flare. The risk for these severe adverse events is far less likely than has been assumed by generations of dermatologists.
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What Is The Usual Dose Of Prednisone
Generally, a higher dose of prednisone, such as 4060 mg daily, is prescribed at first, to gain control of the skin condition. In 24 weeks, the dose is reduced.
Prednisone is best taken as a single dose in the morning, which is thought to reduce steroid-induced suppression of the pituitary-adrenal axis compared to evening dosing.
The maintenance dose should be kept as low as possible to minimise adverse effects.
Steroid dose is commonly characterised as:
- Low dose, eg < 10mg/day of prednisone
- Medium dose, eg 1020 mg/day of prednisone
- High dose, eg > 20mg/day of prednisone, sometimes more than 100 mg/day
Treatment for less than one month is considered short-term treatment. Corticosteroids for a few days or weeks are relatively safe when prescribed for acutedermatitis. Treatment continuing for more than 3 months is regarded as long-term, and results in the majority of undesirable side effects.
Undesirable Side Effecs Of A Short Steroid Course
Undesirable side effects of oral steroids are common, even during a short course. Any individual person may experience none, some, or all of these side effects, which generally go away quickly when the medication is stopped. These side effects include: stomach irritation , fluid retention causing a sense of bloating, hunger, sleeplessness, blurry vision, short temper, and difficulty concentrating. Women may have their menstrual cycle become irregular for a brief while and may develop a vaginal yeast infection. Rare complications include loss of a sense of reality , triggering the onset of diabetes, and injury to the bone in a joint . To avoid some of these side effects, take your oral steroids with food and, if necessary, antacids to minimize stomach upset avoid excessive salt intake and avoid heavy alcohol consumption . Over-the-counter medications are available to treat vaginal yeast infections, including Monistat® and Gyne-lotrimin®.
When the steroid dose is being tapered or stopped, one may experience a different set of side effects. These include: a flu-like stiffness or aching in the joints, lack of energy and appetite, and sadness or teariness that seems inappropriate to ones situation. Bear with them these side effects will go away in a short while.
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Questions To Ask Your Doctor
These are the major questions you will want to discuss with your doctor:
- Why do you think we should try steroids right now for my psoriatic arthritis?
- What health issues do I need to monitor while taking steroids?
- What are the side effects and more serious risks that might occur?
- What results should I expect to see while taking this medication, and how quickly?
- How long will I be taking this medication?
- How much will this drug cost me?
- How much time needs to pass before I can take steroids again?
- Are there any drugs I should not be taking at the same time as steroids?
- Can I breast-feed, become pregnant, or attempt to conceive while taking this medication?
- Are there any activities I should not do while taking this medication?
- What are the next treatment options after this course of steroids finishes?
Who Can And Cant Take Prednisone
Prednisone can be taken by adults and children.
Prednisone isnt suitable for some people.
Tell your doctor before starting prednisone if you:
- have had an allergic reaction to prednisone or any other medicine
- have an infection
- are trying to get pregnant, are already pregnant or you are breastfeeding
- have recently been in contact with someone with shingles, chickenpox or measles
- have recently had, or are about to have, any vaccinations
Make sure your doctor is aware if you have:
- had liver problems
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Myth: Systemic Steroids Cause Pustular Psoriasis
The advent of biologic therapy for psoriasis has changed the landscape of treatments offered to patients. Nevertheless, systemic therapies still play an important role, according to the American Academy of Dermatology psoriasis treatment guidelines, due to their oral route of administration and low cost compared to biologics. They are options for patients with moderate to severe psoriasis that is unresponsive to topical therapies or phototherapy. However, many dermatologists feel that it is inappropriate to prescribe oral steroids to psoriasis patients due to the risk for steroid-induced conversion to pustular psoriasis, the long-term side effects of steroids, and deterioration of psoriasis after withdrawal of steroids.
Pustular psoriasis appears clinically as white pustules surrounded by red skin. The pus consists of white blood cells. There are a number of triggers in addition to systemic steroids, such as internal medications, irritating topical agents, overexposure to UV light, and pregnancy. Stopping an oral steroid abruptly can cause serious disease flares, fatigue, and joint pain.
The benefits of systemic corticosteroids versus the frequency of adverse reactions should be weighed by dermatologists and patients to make evidence-based decisions about treatment. Patients should take oral steroids exactly as prescribed by physicians.
Who Can And Can’t Take Prednisolone
Prednisolone can be taken by adults and children.
Prednisolone isn’t suitable for some people.
Tell your doctor before starting the medicine if you:
- have had an allergic reaction to prednisolone or any other medicine
- have an infection
- are trying to get pregnant, are already pregnant or you are breastfeeding
- have recently been in contact with someone with shingles, chickenpox or measles
- have recently had, or are about to have, any vaccinations
Make sure your doctor is aware if you have:
- had liver problems
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Systemic Steroids Left Out
Clinical practice guidelines in the United States and other jurisdictions do not include systemic steroids as a therapeutic choice in the treatment of psoriasis, Dr. Feldman says.
While Dr. Feldman says he does not frequently use systemic steroids in psoriasis management, clinical practice guidelines that exclude systemic steroids are based on anecdotes rather than trial evidence, and those anecdotes may not be representative of what normally happens in general, community use.
The investigators noted that the survey has limitations: it did not record the dosing of corticosteroids and did not record the duration of prescriptions.
Systemic steroids have not been widely studied as a therapy to manage psoriasis, and the frequent use of systemic steroids to manage psoriasis, as evidenced by the data from the survey, warrant their investigation in clinical trials to assess the true nature of the risk and benefit, according to Dr. Feldman.
Haines Ely, M.D., professor of dermatology at University of California, Davis, says he uses systemic steroids such as dexamethasone for moderate-to-severe presentations of psoriasis and agrees that teaching systemic steroids are contraindicated in the management of psoriasis is unfounded.
Dr. Elys own approach is to use low-dose steroids, such as a dosage of 0.75 mg each morning for 20 days per month, with 10 days off, in addition to pentoxifylline 400 mg three times daily, taken with food.
Short-term approach
What Are The Side Effects And Risks Of Steroids
As noted above, steroids can come with some nasty side effects, including a worsening of skin symptoms as the drug leaves a persons system.
The risk of infection goes up, and skin psoriasis may break down and develop cellulitis or another skin infection, Gonzalez says. Patients blood pressure can go up, they are more at risk for osteoporosis, and their diabetes control is going to be more difficult.
In addition to increased appetite and weight gain, steroids can increase the risk of cataracts as well.
Theyre great for the short run but not great for the long run, Gonzalez says.
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How Does Prednisolone Work
Oral steroids work by attaching themselves to special receptors in cells, resulting in reduced production of inflammatory mediators and inhibiting movement of white cells to sites of inflammation. In eczema, these effects lead to a marked and rapid reduction in the redness, weeping and irritation associated with the condition.
How And When To Take It
It’s important to take prednisolone as your doctor has advised.
The usual dose varies between 5mg and 60mg daily – 1ml of liquid prednisolone is usually equal to 10mg.
Unless your doctor or pharmacist gives you different instructions, it’s best to take prednisolone as a single dose once a day, straight after breakfast. For example, if your dose is 40mg daily, your doctor may tell you to take 8 tablets all at the same time.
Take prednisolone with breakfast so it doesn’t upset your stomach. Taking prednisolone in the morning also means it’s less likely to affect your sleep.
If your prednisolone tablets are labelled as “enteric coated” or “gastro resistant”, you can take these with or without food but make sure to swallow them whole. Do not take indigestion medicines 2 hours before or after taking enteric coated or gastro resistant tablets.
Sometimes, you may be advised to take prednisolone on alternate days only.
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What If I Forget To Take It
If you miss a dose of prednisolone, take it as soon as you remember. If you don’t remember until the following day, skip the missed dose.
Do not take a double dose to make up for a forgotten one.
If you forget doses often, it may help to set an alarm to remind you. You could also ask your pharmacist for advice on other ways to help you remember to take your medicine.
How Does A Systemic Steroid Work
Systemic steroids work in the same way as natural cortisol. Natural cortisol has important effects on the body, including regulation of:
- Protein, carbohydrate, lipid and nucleic acidmetabolism
- Inflammation and immune response
- Distribution and excretion of water and solutes
- Secretion of adrenocorticotrophic hormone from the pituitarygland.
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Whether Or Not To Use Systemic Corticosteroids To Treat A Skin Disease
By Dr. Eileen Murray on October 3, 2017
Dr. Eileen Murray MD FRCPC Disclosures: Served as a consultant for the pharmaceutical industry and participated in clinical research evaluating new therapies for psoriasis and atopic dermatitis. Mitigating potential bias: Treatments or recommendations are unrelated to products/services/treatments involved in disclosure statements.
What I did before
When I started out in dermatology, corticosteroids were the only systemic drug available to treat patients with severe allergic contact dermatitis , atopic dermatitis , drug reactions and those with bullous diseases.
Corticosteroids are potent and excellent immunosuppressive agents. The main problem with systemic use is the high risk of drug interactions, as well as multiple serious acute and long-term side effects.
It was the belief at the time that patients treated oral corticosteroids for short periods, two weeks or less for instance were not adversely affected by treatment.
Severe ACD caused by poison ivy was the disease I treated most frequently with systemic corticosteroids. Patients were given a two-week course of oral Prednisone, 50mg daily for seven days and 25mg daily for another seven . Two weeks of treatment was necessary to prevent recrudescence and completely clear the eruption.
What changed my practice
Osteonecrosis is a known complication of systemic corticosteroid use and was initially believed to occur only in patients who received high doses for extended periods .
Case 1
Is This Drug Safe To Take If I’m Pregnant Or Breastfeeding
- Corticosteroids cross the placenta into the fetus. Compared to other corticosteroids, however, prednisone is less likely to cross the placenta. Chronic use of corticosteroids during the first trimester of pregnancy may cause cleft palate.
- Corticosteroids are secreted in breast milk and can cause side effects in the nursing infant. Prednisone is less likely than other corticosteroids to be secreted in breast milk, but it may still pose a risk to the infant.
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Strengths And Limitations Of This Study
Our findings are particularly of concern given the large number of patients exposed to short term oral corticosteroids in the general adult population. Clinical guidelines typically recommend using the lowest dose of steroids for the shortest period to prevent adverse events.2425 However, we found that even short durations of use, regardless of dose, were associated with increased risks of adverse events and that few patients were using very low doses. Only 6.3% of the prescriptions were for a prednisone equivalent dose of less than 17.5 mg/day, and 1.0% of prescriptions were for less than 7.5 mg/day therefore, we were unable to examine events in patients given very low doses for short periods. A major reason for the higher than expected doses was the widespread use of âfixed doseâ methylprednisolone dosepaks that are tapered over a short period. These dosepaks offer ease of use but do not permit the individualization of drug dosing to minimize exposure.
Undesirable Side Effects Of Prolonged Use Of Oral Steroids
If taken for a long time , daily oral steroids, especially in moderate to high doses, can cause many harmful side effects. These complications of long-term use include cataracts of the eyes, thinning of the bones , weakness of the muscles , fragile skin with a tendency to bruise easily, hair loss, facial hair growth in women, puffy cheeks, a fatty bulge at the base of the back of the neck, and weight gain. Long-term steroid use also predisposes to certain types of unusual infections, to the development of high blood pressure and diabetes, and to shrinkage of the glands that normally make corticosteroid hormones in the body, the adrenal glands. This latter effect makes it dangerous to stop suddenly oral steroids if you have taken them regularly in moderate to high doses for more than about 3 to 4 weeks. You might then become sick from a lack of the normal amounts of corticosteroids in your bloodstream, a condition called”adrenal insufficiency.” Also, should you undergo major surgery or suffer a severe medical illness, your adrenal glands might be unable to produce the extra amounts of corticosteroid hormone usually made under these circumstances. To prevent this from happening, your doctor would routinely provide you with supplemental steroids either by tablet or by intravenous infusion.
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How Does Prednisone Work
In contrast to anabolic steroids , glucocorticoids are used in inflammatory conditions for their antiinflammatory effects. Prednisone has a rapid onset of action, and profoundly affect many parts of the immune system as well as most other body systems.
Corticosteroids mimic the effects of hormones your body naturally produces in your adrenal glands. The adrenal glands sit on top of your kidneys.
When prescribed in doses higher than your bodys usual levels, corticosteroids like prednisone dampen inflammation. This can reduce the symptoms of inflammatory conditions, such as arthritis and asthma.
Prednisone also damp down your immune system, which can help in autoimmune illnesses, like rheumatoid arthritis, where your immune system mistakenly attacks its own tissues.
Are there other steroids?
There are other corticosteroids available, including:
- deflazacort
- methylprednisone
- prednisolone
For most health problems, these steroids are very similar to prednisone in terms of how well they work and how safe they are.
Oral Prednisone Potency:
Prednisone 5 mg is approximately equivalent to:
- Betamethasone 0.75 mg
- Triamcinolone 4 mg
When will I feel better?
This can vary. For some illnesses, you will feel better after a couple of days. Ask your doctor what to expect for your illness.
How long will I take prednisone for?
This depends on your health problem. You may only need a short course of prednisone for up to a week.
Will I put on weight?
Will it affect my mood?