Jay W. Marks, MD, is a board-certified internist and gastroenterologist. He graduated from Yale University School of Medicine and trained in internal medicine and gastroenterology at UCLA/Cedars-Sinai Medical Center in Los Angeles.
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% to 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.
Discussion with the doctor regarding the use of
alendronate (Fosamax) or risedronate (Actonel) in the prevention and the
treatment of corticosteroid induced osteoporosis.
Budesonide (Entocort EC)
Oral budesonide (Entocort
EC) is a topically acting corticosteroid which was been shown to be effective in Crohn's disease, and in enema formulation for left-sided ulcerative colitis with fewer side effects that oral steroids. In a recent meta-analysis, however, it was found to be significantly less likely to induce clinical remission in patients with ulcerative colitis than oral mesalamine after 8 weeks of therapy. Therefore, use of this medication is not recommended at this time to treat flares of ulcerative colitis.
Abdominal pain is pain in the belly and can be acute or chronic. Causes include inflammation, distention of an organ, and loss of the blood supply to an organ. Abdominal pain can reflect a major problem with one of the organs in the abdomen such as the appendix, gallbladder, large and small intestine, pancreas, liver, colon, duodenum, and spleen.
Rectal bleeding (hematochezia) refers to the passage of bright red blood from the anus. Rectal bleeding may be moderate to severe and most bleeding comes from the colon, rectum, or anus. Common causes include anal fissures, hemorrhoids, diverticulitis, and more.
Diarrhea is a change is the frequency and looseness of bowel movements. Cramping, abdominal pain, and the sensation of rectal urgency are all symptoms of diarrhea. Absorbents and anti-motility medications are used to treat diarrhea.
Pink eye, also called conjunctivitis, is redness or irritation of the conjunctivae, the membranes on the inner part of the eyelids and the membranes covering the whites of the eyes. These membranes react to a wide range of bacteria, viruses, allergy-provoking agents, irritants, and toxic agents.
Crohn's disease is a chronic inflammatory disease,
primarily involving the small and large intestine, but which can
affect other parts of the digestive system as well. Abdominal pain, diarrhea, vomiting, fever, and weight loss are
common symptoms.
Anemia is the condition of having less than the normal number of red blood cells or less than the normal quantity of hemoglobin in the blood. The oxygen-carrying capacity of the blood is, therefore, decreased.
Colon cancer is a malignancy that arises from the inner lining of the colon. Most, if not all, of these cancers develop from colonic polyps. Removal of these precancerous polyps can prevent colon cancer.
Clostridium difficile (C. difficile) is a bacterium, and is one of the most common causes of infection of the colon. C. difficile spores are found frequently in hospitals, nursing homes, extended care facilities, and nurseries for newborn infants. They can be found on bedpans, furniture, toilet seats, linens, telephones, stethoscopes, fingernails, rings, floors, infants' rooms, and diaper pails. They even can be carried by pets. Antibiotic-associated (C. difficile) colitis is an infection of the colon caused by C. difficile that occurs primarily among individuals who have been using antibiotics. Treatment for C. difficile colitis hydration, replenishment of electrolyte deficiencies, discontinuing the antibiotic that caused the colitis, and using antibiotics to eradicate the C. difficile bacterium.
Ankylosing spondylitis is a type of arthritis that causes chronic inflammation of the spine. The tendency to develop ankylosing spondylitis is genetically inherited.
Dyspepsia (indigestion) is a functional disease in which the gastrointestinal organs, primarily the stomach and first part of the small intestine, function abnormally. It is a chronic disease in which the symptoms fluctuate infrequency and intensity. Symptoms of dyspepsia include upper abdominal pain, belching, nausea, vomiting, abdominal bloating, early satiety, and abdominal distention (swelling). These symptoms are most often provoked by eating.
Psoriatic arthritis is a disease that causes skin and joint inflammation. Symptoms include painful, stiff, and swollen joints, tendinitis, and organ inflammation. Treatment involves antiinflammatory medications and exercise.
Inflammation of the inner lining of the colon is referred to as colitis. Symptoms of the inflammation of the colon lining include diarrhea, pain, and blood in the stool. There are several causes of colitis including infection, ischemia of the colon, inflammatory bowel disease (Crohn's disease, Ulcerative colitis, or microscopic colitis). Treatment depends on the cause of the colitis.
The inflammatory bowel diseases (IBD) are Crohn's disease (CD) and ulcerative colitis (UC). The intestinal complications of Crohn's disease and ulcerative colitis differ because of the characteristically dissimilar behaviors of the intestinal inflammation in these two diseases.
Erythema nodosum is a skin inflammation that results in reddish, painful, tender lumps most commonly located in the front of the legs below the knees. Erythema nodosum can resolve on its own in 3 to 6 weeks, leaving a bruised area. Treatments include anti-inflammatory medications and cortisone by mouth or injection.
Corticosteroid drugs such as prednisone and prednisolone are commonly used to treat asthma, allergic reactions, RA, and IBD. Steroids such as these do have serious drawbacks such as steroid withdrawal symptoms such as: fatigue, weakness, decreased appetite, weight loss, nausea, vomiting, abdominal pain, and diarrhea. Speak with your healthcare provider prior to tapering off steroid medications.
Bronchiectasis is a condition in which the bronchial tubes of the lung become damaged. Inflammation from infection or other causes destroys the smooth muscles of the bronchial tubes. Bronchiectasis is a form of COPD (which includes emphysema and chronic bronchitis). There are three primary types of bronchiectasis: 1) cylindrical bronchiectasis; 2) saccular bronchiectasis; and 3) cystic bronchiectasis. Bronchiectasis may also be acquired or congenital. The most common symptoms of bronchiectasis are recurrent cough and sputum production. There is no cure for bronchiectasis. Treatment is often geared toward controlling the symptoms of bronchiectasis.
Primary sclerosing cholangitis (PSC) is a chronic, progressive disease of the bile ducts that channel bile from the liver into the intestines. There is an association between primary sclerosing cholangitis and ulcerative colitis and Crohn's disease. Symptoms of primary sclerosing cholangitis include abnormal liver blood tests, itching, fatigue, and jaundice. Primary sclerosing cholangitis is treated with medications and in some cases, liver transplant.
Digestion is the complex process of turning food you eat into the energy you need to survive. The digestive process also involves creating waste to be eliminated, and is made of a series of muscles that coordinate the movement of food.
Biologic rhythms, or biorhythms, are how our bodies respond to the regular phases of the sun, moon, and seasons. A medical chronobiologist studies how the "body clock" or biorhythms affect diseases and how the body clock responds to treatment of diseases and conditions at different times of the day.
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