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MEDICAL CONDITIONS

Medical Author: David S. Kaminstein, MD, FACP, FACG

• Withdrawal symptoms
• Going off steroids
• Steroid Withdrawal At A Glance

Background

In the early 1950s, research leading to the use of cortisone won a Nobel Prize. The drug simulated cortisol, a naturally occurring, anti-inflammatory hormone produced by the adrenal glands. Such corticosteroid drugs ( prednisone , prednisolone , and others) have since benefited many, and are commonly used to treat many conditions including allergic reactions, asthma , rheumatoid arthritis , and inflammatory bowel disease. But they are not without serious drawbacks. The two major problems related to continuous steroid treatment are drug side effects and symptoms due to changes in the balance of normal hormone secretion. The latter results from taking doses greater than our body's natural production (about 7.5 mg of prednisone per day). Thus, steroids are typically given for the shortest possible time possible. Once we begin to decrease or discontinue the dose, however, withdrawal symptoms may occur.

What are steroid withdrawal symptoms?

Steroid withdrawal symptoms can mimic many other medical problems. Weakness, fatigue, decreased appetite, weight loss, nausea, vomiting, diarrhea (which can lead to fluid and electrolyte abnormalities), and abdominal pain are common. Blood pressure can become too low, leading to dizziness or fainting . Blood sugar levels may drop. Women also may note menstrual changes. Less often, joint pain, muscle aches, fever, mental changes, or elevations of calcium may be noted. Decrease in gastrointestinal contractions can occur, leading to dilation of the intestine (ileus).

Going off steroids

Over the years, researchers began to learn why some patients develop symptoms of decreased adrenal function, while others never do. The production of corticosteroids is controlled by a "feedback mechanism," involving the adrenal glands, the pituitary gland and brain-the Hypothalamic-Pituitary-Adrenal Axis" (HPAA). The continuous administration of corticosteroids inhibits this mechanism, causing the HPAA to "hibernate."

We now know that the amount of the drug needed to suppress the HPAA varies from person to person. As a general rule, using large doses for a few days, or smaller doses for more than two weeks, leads to a prolonged decrease in HPAA function.

Thus, steroid use cannot be stopped abruptly. Tapering the drug gives the adrenal glands time to return to their normal patterns of secretion. (It may take a period of time for things to get completely back to normal). How quickly steroids can be tapered depends on continued control of the underlying disease with decreasing doses, and on how quickly our body adjusts to the need to produce its own hormones. If things go well, four to six weeks (or longer) is a reasonable period.

Unfortunately, tapering may not always completely prevent withdrawal symptoms. Present thinking suggests that steroid withdrawal may involve many factors, including a true physiological dependence on corticosteroids. Further, tests of HPAA function do not always correlate with a patient's symptoms, and these tests are of no value while taking steroids. Therefore, it can be difficult to determine the true cause of a patient's symptoms or how he/she may react to stress (for example, from a disease flare-up, procedure, or surgery). Restarting or increasing dosage may be the only solution.

Taking steroids every other morning gives the body a better chance to recover function. The day without the hormone allows natural stimulation of the hypothalamus and pituitary glands. Thus, alternate-day therapy is ideal, if possible, once the disease is under control. It is still not clear whether new steroids being developed will available to decrease the risks of side effects and HPAA suppression.

We must assume that all patients exposed to steroid therapy for even a short time have diminished HPAA function. Patients who have taken steroids noticing any of the above or other unusual symptoms should notify their doctor. Keep in mind that some medications or alcohol can increase the need for larger steroid doses. You should carry a list of all your medications in your wallet to alert medical personnel in case of emergency. This is especially important if you are receiving steroid therapy or have recently stopped taking steroids. Supplementation may be needed during periods of stress, even up to a year after stopping corticosteroid therapy.

Steroid Withdrawal At A Glance

• Synthetic cortisone medications (corticosteroids) simulate cortisol, a naturally occurring, anti-inflammatory hormone produced by the adrenal glands. Such drugs (e.g., prednisone) have since benefited many, but are not without serious drawbacks.
• The two major problems related to continuous steroid treatment are 1)drug side effects and 2)symptoms due to changes in the balance of normal hormone secretion(withdrawal symptoms).
• The production of corticosteroids is controlled by a "feedback mechanism," involving the adrenal glands, the pituitary gland and brain-the "Hypothalamic-Pituitary-Adrenal Axis" (HPAA).
• Using large doses for a few days, or smaller doses for more than two weeks, leads to a prolonged decrease in HPAA function.
• Steroid use cannot be stopped abruptly; tapering the drug gives the adrenal glands time to return to their normal patterns of secretion.
• Withdrawal symptoms (weakness, fatigue, decreased appetite, weight loss, nausea, vomiting, diarrhea, abdominal pain ) can mimic many other medical problems. Some may be life-threatening.
• Tapering may not completely prevent withdrawal symptoms; steroid withdrawal may involve many factors, including a true physiological dependence on corticosteroids.
• Patients should carry a list of all your medications in your wallet to alert medical personnel in case of emergency.
• Supplementation with corticosteroid medication may be needed during periods of stress (such as surgery), even up to a year after stopping corticosteroid therapy.

Reprinted with modification with the kind permission of the Crohn's & Colitis Foundation of America, Inc. For more information about CCFA and its programs, please call 800-932-2423.

David S. Kaminstein, M.D., Physician Advisor
CCFA Chester County Satellite

Matthew Kane, M.D., Endocrinologist
The Chester County Hospital, PA
Copied from the PRODIGY(R) service 02/16/96 19:29

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