Ulcerative Colitis (cont.)
Systemic Corticosteroids (including side
effects)
Corticosteroids (Prednisone, prednisolone, hydrocortisone, etc.) have been
used for many years in the treatment of patients with moderate to severe Crohn's disease
and ulcerative colitis or who fail to respond to optimal
doses of 5-ASA compounds. Unlike the 5-ASA compounds, corticosteroids do not
require direct contact with the inflamed intestinal tissues to be effective.
Oral corticosteroids are potent anti-inflammatory agents. After
absorption, corticosteroids exert prompt anti-inflammatory action throughout the
body. Consequently, they are used in treating Crohn's enteritis, ileitis, and
ileocolitis, as well as ulcerative and Crohn's colitis. In critically ill
patients, intravenous corticosteroids (such as hydrocortisone) can be given in
the hospital.
Corticosteroids are faster acting than the 5-ASA compounds.
Patients frequently experience improvement in their symptoms within days of
starting corticosteroids. Corticosteroids, however, do not appear to be
useful in maintaining remissions in ulcerative colitis.
Corticosteroid side effects
Side effects of corticosteroids depend on the dose and duration of use. Short
courses of prednisone, for example, usually are well tolerated with few and mild
side effects. Long term, high doses of corticosteroids usually produce
predictable and potentially serious side effects. Common side effects include
rounding of the face (moon face), acne, increased body hair, diabetes, weight
gain, high blood pressure, cataracts, glaucoma, increased susceptibility to
infections, muscle weakness, depression,
insomnia, mood swings, personality changes, irritability, and thinning of the
bones (osteoporosis) with an accompanying increased risk of compression
fractures of the spine. Children on
corticosteroids can experience stunted growth.
The most serious
complication from long term corticosteroid use is aseptic necrosis of the hip joints. Aseptic necrosis means death of bone
tissue. It is a painful condition that can ultimately lead to the need for surgical replacement of the hips. Aseptic necrosis also has been reported in knee joints. It is unknown how
corticosteroids cause aseptic necrosis. The estimated incidence of aseptic necrosis among
corticosteroid users is 3-4%. Patients on corticosteroids who develop pain in
the hips or knees should report the pain to their doctors promptly. Early diagnosis of
aseptic necrosis with cessation of corticosteroids has been reported in some patients to decrease
the severity of the condition and possibly help avoid hip replacement.
Prolonged use of
corticosteroids can depress the ability of the body's adrenal glands to produce
cortisol (a natural corticosteroid necessary for
proper functioning of the body). Abruptly discontinuing corticosteroids can
cause symptoms due to a lack of natural cortisol (a condition called adrenal
insufficiency). Symptoms of adrenal insufficiency include nausea, vomiting, and
even shock. Withdrawing corticosteroids too quickly also can produce symptoms of
joint aches, fever, and malaise. Therefore, corticosteroids need to be gradually
reduced rather than abruptly stopped.
Even after the corticosteroids are discontinued, the adrenal glands' ability
to produce cortisol can remain depressed for months to two years. The
depressed adrenal glands may not be able to produce enough cortisol to help the
body handle stress such as accidents, surgery, and infections. These patients
will need treatment with corticosteroids (prednisone, hydrocortisone, etc.) during stressful
situations to avoid developing adrenal insufficiency.
Because
corticosteroids are not useful in maintaining remission in ulcerative colitis
and Crohn's disease and because they have predictable and potentially serious
side effects, these drugs should be used for the shortest possible length of
time.
Proper Use of Corticosteroids
Once the decision is made to use oral corticosteroids, treatment
usually is initiated with prednisone, 40-60 mg daily. The majority of patients
with ulcerative colitis respond with an improvement in symptoms. Once symptoms
improve, prednisone is reduced by 5-10 mg per week until the
dose of 20 mg per day is reached. The dose then is tapered at a slower rate
until the prednisone ultimately is discontinued. Gradually reducing corticosteroids not only
minimizes the symptoms of adrenal insufficiency, it also reduces the chances of
abrupt relapse of the colitis.
Many doctors use 5-ASA compounds at the same time as corticosteroids. In
patients who achieve remission with systemic corticosteroids, 5-ASA compounds
such as Asacol are often continued to maintain remissions.
In patients whose
symptoms return during reduction of the dose of corticosteroid, the dose of corticosteroids is
increased slightly to control the symptoms. Once the symptoms
are under control, the reduction can resume at a slower pace. Some patients
become corticosteroid dependent. These patients consistently develop symptoms of colitis
whenever the corticosteroid dose reaches below a certain level. In
patients who are corticosteroid dependent or who are unresponsive
to corticosteroids, other anti-inflammatory medications, immunomodulator
medications or surgery are considered.
The management of patients who are corticosteroid dependent
or patients with severe disease which responds poorly to medications is complex.
Doctors who are experienced in treating inflammatory bowel disease and in using the immunomodulators
should evaluate these patients.
Preventing Corticosteroid-induced Osteoporosis
Long-term use of
corticosteroids such as prednisolone or prednisone can cause osteoporosis . Corticosteroids cause
decreased calcium absorption from the intestines and increased loss of
calcium from the kidneys and bones. Increasing dietary calcium intake is
important but alone cannot halt corticosteroid-induced bone loss. Management
of patients on long term corticosteroids should include:
- Adequate calcium
(1000 mg daily if premenopausal, 1500 mg daily if postmenopausal) and vitamin
D (800 units daily) intake.
- Periodic review
with the doctor on the need for continued corticosteroid
treatment and the lowest effective dose if continued treatment is
necessary.
- A bone density
study to measure the extent of bone loss in patients taking
corticosteroids for more than three months.
- Regular weight-bearing exercise, and
stop smoking cigarettes.
- Discussion with the doctor regarding the use of
alendronate (Fosamax) or risedronate (Actonel) in the prevention and the
treatment of corticosteroid induced osteoporosis.
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