Definition

By corticosteroids we usually mean glucosecorticosteroids, although corticosteroids also include mineral corticosteroids. Natural corticosteroids are produced in the adrenal cortex (cortex), while prednisolone and hydrocortisone are synthetic corticosteroids. Of these, prednisolone is the most widely used in rheumatology. Cortisone was synthesized at the Mayo Clinic and used Rheumatoid arthritis (RA) in 1948/49. Cortisone treatment immediately has a calming effect on many types of rheumatic inflammation, but must be used with caution.

Effect

Cortisone treatment has an immediate depressant effect on the immune system, which is too active in rheumatic inflammation. This is done by the drug binding to the glucocorticoid receptor and thus triggering immunosuppressive substances (cytokines). This affects, among other things, T lymphocytes and monocytes. Different synthetic cortisone preparations have been made that can be divided into groups, depending on how long they last in the body and how strong they are compared to the body's own cortisone (cortisol):

Short-acting: Hydrocortisone (cortisol) and cortisone. Biological action time is 8-12 hours. Anti-inflammatory effect: factor 0,8 (cortisone) - 1 (hydrocortisone). Moderate mineralocorticoid action.
Drugs: Prednisolone, prednisone, methylprednisolone (Depot Medrol), triamcinolone (Ledercort, Lederspan, Kenacort). Biological action time 15-48 hours. Anti-inflammatory effect: factor 4 (prednisolone) - 5 (methyl-prednisolone and triamcinolone). Low mineralocorticoid effect.
Long-acting: Betamethasone, Dexamethasone (Decadron). Biological action time of 36-72 hours. Anti-inflammatory effect: factor 25-30. No mineralocorticoid effect.

Side effects

The risk of side effects from cortisone treatment is completely dependent on the dosage and how long the treatment lasts. There are also large individual differences. For Prednisolone, a low dose is considered to be less than 7,5 mg / day and a high dose more than 30 mg / day (reference: Buttgereit F, 2002).

Weight gain occurs on the background of increased appetite and at high doses also tends to increased fluid in the body.

Redistribution of fats at high doses can result in a rounder face and larger stomach. At prednisolone doses below 7,5 mg / day, this will decrease. The degree of side effect varies from person to person.

Diabetes mellitus (diabetes) is seen, especially when high doses must be given to predisposed individuals who, for example, have diabetes in the immediate family. Blood sugar control may therefore be appropriate during treatment.

bone necrosis (osteonecrosis) is rapid destruction of bone substance that can be seen at the hip, shoulder, wrist or ankles. The risk is greatest at high doses.

Infections. One is more susceptible to all types of infection, especially at high doses over a long period of time. Old age, diabetes and concomitant use of other immunosuppressive drugs such as Biological drugs og DMARDs increases the risk.

Fragile bones (osteoporosis) may occur with use over several months or years. Menopausal women and slim people are most at risk. In addition, genetic conditions may be important. Measurement of bone mass / bone density and preventive measures may be relevant.

Lack of self-production of cortisone (in the adrenal glands). During cortisone treatment, the adrenal glands reduce their own production of cortisol and they need weeks-months to rebuild it when one stops taking the drug. The symptoms may be similar Addison's disease. To avoid cortisone deficiency, one must therefore not abruptly end a long-term prednisolone treatment that has lasted for weeks or more.

Measures against side effects:

Measure bone density / bone mass at risk of developing osteoporosis
Sufficient calcium and Vitamin D intake. For example, by taking Calcigran Forte to prevent osteoporosis.
Proper diet
Physical activity regularly
Stop smoking
Avoid high alcohol consumption
Vaccines against infection in predisposed persons (eg elderly): Influenza (annually), pneumococci (pneumonia) (every 10 years, herpes zoster / shingles).

Pregnancy. The lowest possible doses are used. At high doses there is an increased risk of complications. Please see info from NKSR

Joint injections

Cortisone can be injected into joints to alleviate a rheumatic inflammation (arthritis). The advantage is that the drug gets where it is needed most and the body or is loaded little. The effect can therefore be very good. The drug triamcinolone (Lederspan) is often used. The injections can be made ultrasound-guided for good accuracy (Norberg LB, 2018). Complications of joint puncture are rare. Pain and light bleeding usually occur due to the puncture itself. Development of thin and sunken skin (skin atrophy) and whitish color (loss of pigment) is seen in approx. 1%. The risk of infection (septic / infectious arthritis) is low at 0,037% -0,01% (references: Geirsson AJ; Hartmann H, 2000).

Intravenous treatment

Corticosteroids given in large doses intravenously (methylprednisolone / SoluMedrol pulse therapy) are used in severe disease, such as in organ-threatening complications. Caution should be exercised when pulse treatment with methyl-prednisolone in patients with heart disease, in diabetes and other conditions with an increased risk of complications. One can assess the level of salts (potassium, calcium) and blood sugar in the blood and do ECG tests before and during treatment.

Calculate equivalent corticosteroid doses here

EULAR recommendations for corticosteroid treatment (reference: Duru N, 2013)