Oral Steroids

What is an oral steroid?

Steroids are a type of hormone produced by the body. They have many functions including reducing inflammation and suppressing the body's immune system.

Steroid medicines are man-made but are similar to these natural hormones.

Steroid medicines used to treat disease are also called corticosteroids.

Types of oral steroids

The most commonly used corticosteroid medicine type is glucocorticoids. These include steroids such as:

• Prednisolone.
• Betamethasone.
• Dexamethasone.
• Hydrocortisone.
• Methylprednisolone.
• Deflazacort.

The other group are called mineralocorticoids. Mineralocorticoids are usually used for replacing steroids the body isn't producing itself. The one commonly used is fludrocortisone.

What are oral steroids used for?

Oral steroids are used to treat a large number of conditions, usually by reducing inflammation or the effect of the persons immune system. Some examples include:

• Inflammatory bowel diseases (for example, Crohn's disease, ulcerative colitis).
• Autoimmune diseases (for example, systemic lupus erythematosus (SLE), autoimmune hepatitis).
• Relapses that occur in multiple sclerosis.
• Joint and muscle diseases (for example, rheumatoid arthritis, polymyalgia rheumatica).
• Allergies.
• Asthma.
• Chronic obstructive pulmonary disease (COPD).
• Croup.

Oral steroids are also used to treat the effects of some cancers or to treat conditions in which a person is not making enough of their own natural steroids (for example, in Addison's disease, congenital adrenal hyperplasia and hypopituitarism).

What is the dose?

This will vary depending on the steroid used and the condition for which they are prescribed. For short courses, usually a relatively high dose is prescribed each day, for a few days or a week or so, and then stopped abruptly at the end of the course. If taken for longer than this it is important to reduce the dose gradually before stopping.

For those who have to take oral steroids for a longer time, a common treatment plan is to start with a high dose to control symptoms. Often the dose is then slowly reduced to the lowest daily dose that keeps symptoms away. The length of treatment can vary, depending on the disease. Sometimes the steroid treatment is gradually stopped if the condition improves, and restarted if it worsens. In some conditions steroids are needed lifelong.

When do I take it?

Your pharmacist will give you exact instructions. It will depend on which steroid you take, and what it is for. Usually steroids are taken first thing in the morning, with food.

Side-effects of oral steroids

A short course of oral steroids usually causes no side-effects.

Side-effects are more likely to occur if you take a long course of oral steroids (more than 2-3 months), or if you take short courses repeatedly.

The higher the dose, the greater the risk of side-effects. This is why if you take steroids for long periods of time then your medical professionals will try to use the lowest possible dose which controls your symptoms.. Some diseases need a higher dose than others to control symptoms. Even for the same disease, the dose needed often varies from person to person.

For many diseases, the benefits of taking oral steroids usually outweigh the side-effects. However, side-effects can sometimes be troublesome. You should read the information leaflet that comes with your medicine packet for a full list of possible side-effects. The main possible side-effects include the following:

'Thinning' of the bones (osteoporosis)

If you are going to take steroids long-term you may be advised to take medications or supplements to strengthen your bones and help prevent osteoporosis.

Weight gain

As well as gaining weight, you may also develop puffiness around the face and at the base of the neck.

Increased chance of infections

There is a higher chance of developing an infection, or an infection being more serious because steroids may suppress the immune system. In particular, if you have not had chickenpox or measles in the past (and so are not immune) you will be advised to avoid people with chickenpox, shingles or measles. Tell your doctor if you come into contact with people with these conditions.

Infections which may remain in your body, such as tuberculosis (TB), or herpes, may recur if you had it in the past.

Increase in blood pressure

There may be an increase in blood pressure, so have your blood pressure checked regularly. It can be treated if it becomes high.

High blood sugar (hyperglycaemia)

Steroids can cause raised blood sugar, leading some people to develop diabetes or people with diabetes may need more medication to control their blood sugars. If you take long-term steroids, your doctor may arrange a yearly blood sugar test to check for diabetes.

Skin problems

Skin problems such as slower healing after injuries, thinning skin, and easy bruising. Stretchmarks sometimes develop.

Muscle weakness

Muscle weakness improves after the steroid is stopped. Physiotherapy may help treat this.

Mood and behavioural changes

Some people actually feel better in themselves when they take steroids, noticing increased energy. However, steroids may aggravate depression and other serious mental health problems, and may occasionally cause mental health problems. If this side-effect occurs, it tends to happen within a few weeks of starting treatment and is more likely with higher doses. Some people even become confused, and irritable; they may develop delusional and suicidal thoughts. These mental health effects can also occur when steroid treatment is being withdrawn. Seek medical advice if worrying mood or behavioural changes occur.

An increased risk of developing cataracts

Tell your doctor or optician if you develop any problems with your sight, such as blurred vision as there is an increased risk of developing cataracts.

An increased risk of duodenal ulcers and stomach ulcers

As there is an increased risk of duodenal ulcers and stomach ulcers, tell your doctor if you develop indigestion, acid reflux or tummy (abdominal) pains. If you are at risk of these your doctor may prescribe a medication to reduce the symptoms and the risk of developing an ulcer.

The above are only the main possible side-effects which may affect some people who take steroids. There is often a balance between the risk of side-effects against the symptoms and damage that may result from some diseases if they are not treated. Less common side-effects are not listed above but will be included on the leaflet that comes with your medicine.

Who cannot take oral corticosteroids?

There are very few people who cannot take oral corticosteroids.

Oral steroids are used with caution in people who:

• Have liver problems.
• Have a history of severe mental health problems.
• Have a history of stomach ulcers or duodenal ulcers.
• Have 'thinning' of the bones (osteoporosis).
• Have cataracts.
• Have certain heart conditions, such as a recent heart attack, heart failure, or high blood pressure (hypertension).
• Have diabetes.
• Have epilepsy.
• Have systemic sclerosis.
• Are pregnant.
• Are breastfeeding.

Always tell your doctor if you are pregnant or may be pregnant, or are breastfeeding. Your doctor and pharmacist can then give advice about the safest way to manage your symptoms.

How do I stop oral steroids?

If you have taken a short course of an oral steroid, you may be advised to abruptly stop taking the tablets at the end of the course. Whether you can stop abruptly or need to gradually reduce the dose before stopping depends on the dose taken, how long you have taken them for and whether you take repeated courses.

When not to stop taking oral steroids suddenly

Do not stop taking oral steroids suddenly if you have been taking a dose of 40mg, or higher than this, for more than 1 week or taking lower doses for 3 weeks or more. It probably does no harm to forget the odd dose. However, you may have serious withdrawal effects once your body is used to the steroids. These may develop within a few days if you stop oral steroids suddenly. Any change in dose should be supervised by a doctor.

Why is it necessary to reduce the dose gradually before stopping oral steroids?

Your body normally makes steroid hormones by itself which are necessary for the body to function. When you take oral steroids for a few weeks or more, your body may reduce or stop making its own steroid hormones. If you then stop taking oral steroids suddenly, your body does not have the hormones it needs to function.. This can cause various withdrawal symptoms which can be serious and life-threatening. The symptoms can include:

• Weakness.
• Tiredness.
• Feeling sick (nausea).
• Being sick (vomiting).
• Loss of appetite.
• Diarrhoea.
• Tummy (abdominal) pain.
• Low blood sugar (hypoglycaemia).
• Low blood pressure (hypotension) which can cause dizziness, fainting or collapse.
• Developing patches of darker coloured skin.

If the dose is reduced gradually, the body gradually resumes its natural production of steroids and the withdrawal symptoms do not occur.

Some other important points about oral steroids

• Do not take anti-inflammatory painkillers (such as ibuprofen) whilst taking steroids (unless advised by a doctor). The two together further increase the risk of a stomach or duodenal ulcer developing
• Most people who take regular steroids carry a steroid card which should be provided by the person who prescribes or supplies your medicine, and/or they wear a medical emergency identification bracelet or equivalent. This gives details of your dose, your condition, etc, in case of emergencies.
• The dose of steroid may need to be increased for a short time if you are ill with other specific conditions. For example, if you have a serious infection, or have an operation. This is because you need more steroids during physical stress placed on the body by these events.
• Speak to your doctor if you have any concerns about your steroid treatment

Can I take other medicines when I am taking steroids?

Many medicines can affect or be affected by oral steroids. This means the steroid could affect how they work, either resulting in the other medicine being ineffective, or having more side-effects than usual. Or they can interact the other way around, with the other medicine affecting the corticosteroid.

Examples of medicines which can interact with steroids include:

• Warfarin (a blood-thinning medicine to prevent blood clots).
• Non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, diclofenac and naproxen. Both NSAIDs and steroids can cause gut ulcers as a side-effect, so when taken together, the risk is particularly high. A medicine such as a proton pump inhibitor (PPI) may need to be taken to reduce this risk.
• Live vaccines. Most vaccines do not contain the germ they are protecting against, but a few do. These include the measles, mumps and rubella (MMR) vaccine, rotavirus, yellow fever and tuberculosis (TB). People taking steroid medication and people who are living with those taking steroid medication should avoid live vaccines. If these are necessary discuss this with your doctor.
• Medicines for epilepsy, specifically carbamazepine, phenytoin and phenobarbital.
• Medicines for diabetes. After starting steroids blood sugars should be tested more frequently, and then the doses of medicines for diabetes can be altered if required
• Digoxin.
• 'Water tablets' (diuretics).
• Treatments for HIV and AIDS.

What should I do if I am taking one of the medicines which interact with oral steroids?

As long as your doctor knows you are taking this, they can advise accordingly.

Can I take oral steroids if I am pregnant or breastfeeding?

If you are pregnant or may be pregnant, or breastfeeding, it is important to tell your doctor. They can then help you make a choice which is right for you. Usually steroids can safely be used safely in pregnant or breastfeeding women. The lowest dose possible for the shortest possible amount of time would be used. Some, but not all, studies looking at steroid use in the first 12 weeks of pregnancy, showed they may slightly increase the risk of your baby having a cleft lip and/or palate. Ask your doctor about the risks and benefits.