Corticosteroid treatment side effects. Side effects of glucocorticoids. Interaction with other hormones

Hormonal medications of any group cause concern among patients. Many people categorically refuse to take such drugs. All hormones have gotten a bad name glucocorticoids (glucocorticosteroids). The problems of treatment with these medications remain the focus of attention of doctors of all specialties today.

Problems of treatment with glucocorticoids

The powerful anti-inflammatory effect of glucocorticoid drugs has led to their widespread use in therapeutic practice for a variety of diseases. The reason for the use of these hormones may be glomerulonephritis or viral hepatitis. In the body, steroids are produced in the endocrine glands - the adrenal glands. Synthetic hormonal drugs are used as medications. Most often, doctors prescribe Prednisolone, Cortisone, Hydrocortisone, Dexamethasone. These medications can have a pronounced effect when administered by injection, in the form of tablets, and even topically (inhalations, ointments, suppositories). In any case, all of these drugs have significant side effects. Another problem with the use of glucocorticoids is the need to gradually reduce the dose of the drug before discontinuation.

Side effects of glucocorticoid treatment

Treatment with drugs in this group leads to a variety of side effects. These include changes in appearance, thinning hair, excess hair growth in women on the face and body, acne, thinning skin, stretch marks on the abdominal skin, and bruising due to fragility of blood vessels. In large doses, steroids (glucocorticoids are steroids in structure) have a pronounced negative effect on the psyche of patients. Patients may develop anxiety, a decrease in general mood, and in severe cases, acute dysfunction of higher nervous activity - psychosis. The gastrointestinal tract also suffers. The patient may develop a peptic ulcer. Severe complications may arise from the musculoskeletal system. This can reduce growth and pain in the back from compression fractures, wasting and weakness of the hip muscles. People receiving glucocorticoids for a long time may develop immunodeficiency, arterial hypertension, and obesity. Another problem may be decreased vision due to cataracts. Women may have dysmenorrhea. All these side effects are related to the dosage and duration of taking the drug, so they must be reduced to a minimum. In some patients, some of the manifestations may be barely noticeable.

Complications of glucocorticoid withdrawal

Long-term use of glucocorticoids in large doses leads to the fact that the adrenal glands stop producing these hormones. The tissue of these endocrine glands gradually atrophies. In addition, the connection between the adrenal glands and the hypothalamic-pituitary system is lost. The mechanisms of their interaction are disrupted. As a result of all these processes, the adrenal glands lose the ability to adequately respond to the newly emerged need for their own hormones. Therefore, if a patient takes glucocorticoids for several weeks, and then one day refuses them, a serious life-threatening complication may develop. This complication is... The main manifestation of this condition is a drop in blood pressure. Usually its numbers are significantly lower than 90/60 mmHg. In addition, nausea, vomiting, and repeated loose stools often develop. Half of the patients experience severe pain along the intestines. The patient's mental state also suffers. The patient may experience delirium, lethargy, and stupor. Sometimes, due to the resulting cerebral edema, epileptic seizures appear. To avoid acute adrenal insufficiency, glucocorticoids should be discontinued gradually, reducing the dose weekly and only under the supervision of specialists.

Glucocorticoids are drugs that should only be prescribed by a specially trained specialist. Self-medication with these hormones is absolutely unacceptable and poses a serious threat to life and health.

Each drug, like a coin, has two sides: on the one hand, the therapeutic effect, and on the other, side effects.

Unfortunately, great minds have not yet come up with harmless medicines that only bring benefits without harming health.

In such an ambiguous situation, the attending physician must carefully weigh the benefits of the drug and the harms of its action before prescribing it to the patient.

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Subject: Grandma's blood sugar has returned to normal!

From: Christina ( [email protected])

To: Site Administration

Christina
Moscow

My grandmother has been suffering from diabetes for a long time (type 2), but recently there have been complications in her legs and internal organs.

Glucocorticoids are a type of human hormone that is produced by the adrenal glands, or more precisely by their cortex. They take an active part in the processes occurring in the body. Such hormones begin to act primarily in emergency situations: shock, stress, trauma. This is the reason for their use in medicine to provide anti-inflammatory and anti-allergic effects.

The mechanism of their work is approximately as follows:

1. the hormone, entering the cell, affects the receptors;
2. genes that regulate the body's immune response are activated;
3. active gene work reduces inflammation and suppresses the patient’s immune system.

Also, glucocorticoid hormones stimulate blood vessels to constrict, making them less permeable, while the work of liver cells is activated. Thus, the body protects itself from toxins and shock.

Indications for glucocorticoid therapy:

• disorders of the adrenal glands;
• diseases of the musculoskeletal system;
• allergy;
• asthma;
• skin diseases;
• sarcoidosis;
• Crohn's disease.

If the patient is burdened with asthma or allergies, then hormones are prescribed in the form of inhalations.

Side effects

Glucocorticoids have a great influence on the production of other hormones in the body. The thyroid gland is most susceptible to this effect. Under the influence of adrenal hormones, its activity decreases.

Side effects from glucocorticoid therapy can be divided into two groups: local and systemic.

Most often, undesirable consequences of this kind occur after the use of inhalation drugs containing the hormone.

The patient may be concerned about:

• itching in the nose;
• frequent sneezing;
• soreness in the nasopharynx;
• candidiasis in the mouth;
• cough.

As a rule, they are temporary and disappear completely after hormonal therapy is discontinued.

The list of systemic side effects is much more impressive. It mainly depends on which system was the most vulnerable.

Steroid drugs completely suppress the action of the adrenal glands. And even after stopping steroids, they are not able to work “at full strength” again for a long time. Withdrawal syndrome is dangerous because the body may experience an acute lack of glucocorticoids. Even a small injury or stress can cause great harm to the body. A person with a lack of this hormone feels lethargic and apathetic. There is a lack of appetite and significant weight loss.

The greatest concern is the hypotensive ability of steroids. A decrease in blood pressure under their influence is extremely difficult to treat with traditional drugs.

Steroid drugs suppress human immunity, mainly by reducing the body's resistance to bacterial infections. The risk of infection is directly dependent on the dose of glucocorticoids: the higher the dose, the higher the risk. This effect is the root cause of the development of complications, often fatal.

With hormonal therapy, infections in the body are in a latent form, only an increase in body temperature is possible. To avoid such side effects, influenza and pneumococcal vaccines are recommended for patients before treatment. It would also be a good idea to do a tuberculin test.

Often, glucocorticoids cause mental disorders in patients. This can manifest itself either in slight irritability or in severe depression and psychosis.

Often, the consequence of hormonal therapy can even be a change in the patient’s appearance: weight gain, rounding of the face, acne, purple stretch marks, bruises. As a rule, such undesirable effects are reduced or completely disappear after reducing the dose.

Exceeding the required dose of any medicine has a negative impact on the health and well-being of the patient. Overdose of glucocorticoids does not happen very often.

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Overdose symptoms:

• swelling;
• disturbance of electrolyte balance in the body;
• convulsions.

In extremely rare cases, abdominal pain, heartburn, nausea and vomiting are possible.

At the first symptoms of an overdose of a hormonal drug, its use should be stopped. Treatment is symptomatic. No specific therapy is provided.

If the patient takes any medication regularly, the doctor must be notified about this before prescribing glucocorticoids. Some drugs interact with each other and may cause unwanted effects.

Concomitant use of medications to reduce gastric acidity with steroids weakens the effect of the latter. The combined use of hormones and aspirin can provoke the formation of ulcers in the gastrointestinal tract, and with paracetamol - a manifold increase in its toxicity.

Medicines intended to lower glucose levels lose their effect if they are used in parallel with glucocorticoids. Steroid hormones in combination with diuretics can cause potassium to be washed out of the body.

Such drugs should be taken with caution by elderly people and patients with liver cirrhosis, as in this case the effect of hormones may be enhanced.

Live vaccine injections are contraindicated in patients undergoing immunosuppressive hormone therapy.

There are some groups of patients for whom glucocorticoid therapy is contraindicated.

These include:

• sick;
• patients with a history of mental disorders;
• patients with gastrointestinal diseases;
• patients with severe hypertension and/or heart failure.

The rest can use hormonal therapy. To minimize the risk of side effects, you need to closely monitor your health. If any pathologies are detected, you should inform your doctor.

All patients undergoing treatment with steroids, regardless of their type or type, are recommended to take vitamin and mineral complexes, with special attention to calcium and vitamin D. In some cases, insulin may be necessary.

For clarity and ease of perception, all side effects and methods for their management are presented in the table.

Table: “Adverse effects from steroid therapy and ways to reduce them”

Unfortunately, treatment with glucocorticoids is almost always associated with the appearance of certain side effects. Responsibility for this lies with both the doctor and the patient. The doctor is required to thoroughly study the patient's medical history in order to exclude the possibility of incompatibility of medications taken. The patient, in turn, must strictly adhere to the dosage and time of taking the medications.

Glucocorticoids are serious drugs. Their use should be justified only by extreme necessity. Therapy should be as short as possible.

Taking hormones in any case will upset the balance in the body. The main thing is that the consequences for the patient are minimal.

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All glucocorticoids have similar side effects, which depend on the dose and duration of treatment.

1. Suppression of adrenal cortex function. Glucocorticoids suppress the function of the hypothalamic-pituitary-adrenal cortex system. This effect may persist for months after cessation of treatment and depends on the dose used, frequency of administration and duration of therapy. The effect on the adrenal cortex can be reduced if short-acting drugs such as prednisone or methylprednisolone are used in small doses instead of long-acting drugs (dexamethasone). It is advisable to take the entire daily dose in the early morning hours, which is most consistent with the physiological rhythm of endogenous cortisol secretion. When taken every other day, short-acting glucocorticoids are used and a single dose is also prescribed in the early morning hours. Under the influence of stress (abdominal surgery, severe acute concomitant diseases, etc.), hypofunction of the adrenal cortex often occurs, manifested by lack of appetite, weight loss, drowsiness, fever and orthostatic hypotension. The mineralocorticoid function of the adrenal cortex is preserved, so hyperkalemia and hyponatremia, characteristic of primary adrenal insufficiency, are usually absent. Patients should wear a special bracelet or have a medical card with them so that in an emergency situation the doctor knows about the need to immediately administer glucocorticoids. In patients taking more than 10 mg of prednisone per day (or an equivalent dose of another drug) for several weeks, some degree of adrenal suppression may persist for up to 1 year after discontinuation.
2. Immune suppression. Glucocorticoids reduce resistance to infections, especially bacterial ones; the risk of infection directly depends on the dose of glucocorticoids and remains the main cause of complications and death in patients with SLE. As a result of treatment with steroids, a local infection can become systemic, a latent infection can become active, and it can also be caused by non-pathogenic microorganisms. During glucocorticoid therapy, infections may be hidden, but body temperature usually rises. As a preventive measure, immunization with influenza and pneumococcal vaccines, which do not cause exacerbation of SLE, is recommended. Before starting treatment with glucocorticoids, it is advisable to conduct a tuberculin skin test.
3. Changes in appearance include: rounding of the face, weight gain, redistribution of fat deposits, hirsutism, acne, purple stretch marks, bruising with minimal trauma. These changes decrease or disappear after dose reduction.
4. Mental disorders range from mild irritability, euphoria and sleep disturbances to severe depression or psychosis (the latter may be mistakenly interpreted as lupus damage to the central nervous system).
5. Hyperglycemia may occur or increase during treatment with glucocorticoids, but, as a rule, does not serve as a contraindication for their use. Insulin may be required; ketoacidosis develops rarely.
6. Water-electrolyte imbalance include sodium retention and hypokalemia. Particular difficulties in treatment arise with congestive heart failure and edema.
7. Glucocorticoids can cause or increase arterial hypertension. IV pulse therapy with steroids often worsens pre-existing hypertension if it is poorly responsive to treatment.
8. Osteopenia with compression fractures of vertebral bodies often develops with long-term glucocorticoid therapy. Therefore, patients should receive calcium ions (1-1.5 g/day orally). Vitamin D and thiazide diuretics may be helpful. For postmenopausal women with an increased risk of osteopenia, estrogens are usually indicated, but the results of their use in SLE are controversial. Calcitonics and bisphosphonates can also be used. Physical exercises that stimulate osteogenesis are recommended.
9. Steroid myopathy characterized by damage to the muscles mainly of the shoulder and pelvic girdle. Muscle weakness is noted, but there is no pain; the activity of blood enzymes of muscle origin and electromyographic indicators, in contrast to inflammatory muscle damage, do not change. Muscle biopsy is performed only in rare cases when it is necessary to exclude inflammation. The possibility of steroid myopathy decreases as the dose of glucocorticoids is reduced and intense exercise is performed, but full recovery may take several months.
10. Ophthalmological disorders include increased intraocular pressure (sometimes due to progression of glaucoma) and posterior subcapsular cataracts.
11. Ischemic bone necrosis(aseptic, avascular necrosis, osteonecrosis) can also occur during steroid therapy. These complications are often multiple, affecting the femoral head, humerus, and tibial plateau. Early disorders are detected by isotope scintigraphy and MRI. The appearance of characteristic x-ray changes indicates an advanced process. Surgical bone decompression may be effective in early ischemic necrosis, but evaluations of this treatment are controversial.
12. Other side effects of glucocorticoids include hyperlipidemia, menstrual irregularities, increased sweating, especially at night, and benign intracranial hypertension (pseudotumor cerebri). Thrombophlebitis, necrotizing arteritis, pancreatitis and peptic ulcers are sometimes associated with the action of glucocorticoids, but evidence of this association is insufficient.

The side effects of glucocorticoids can be significantly reduced and, in some cases, completely eliminated.

A little glucocorticoid, like a glass of wine,

may be useful to many (patients),

Too many glucocorticoids, like a bottle of wine, are bad for everyone.

T. Pincus.

Glucocorticosteroids have been compared to a double-edged sword. On the one hand, they are drugs with powerful therapeutic activity that can quickly achieve positive dynamics in the patient’s condition, for example, reducing pain in severe articular syndrome in RA, and on the other hand, numerous adverse reactions are the reason for turning to GCs when exhausted possibilities of therapy with other drugs. Side effects of GCs are usually divided into manifestations caused by hypercortisolism (drug-induced Itsenko-Cushing syndrome) and associated with suppression of the activity of the endogenous hypothalamic-pituitary-adrenal system (Table 5). The most common side effect is weight gain with upper torso obesity. Obesity is a consequence of the anabolic effect of GC on fat metabolism - increased synthesis of triglycerides, fatty acids and cholesterol with fat redistribution.

It is assumed that in many cases the development of impotence and menstrual irregularities may be associated not only with the use of GCs, but also with the underlying disease.

Table 5

Side effects of glucocorticosteroids

Hyperglycemia is not uncommon, especially at the beginning of treatment. It can be compensated by an increase in insulin synthesis, but in some cases it leads to diabetes mellitus.

Sodium (water) retention and potassium loss occur due to the mineralocorticoid properties of some drugs (incidence 1-10%).

Long-term treatment with GCs can induce atherosclerotic vascular damage, which is associated with the ability of GCs to cause lipid metabolism disorders.

The mechanism of ischemic bone necrosis is not clear. It is assumed that hypertrophy of bone marrow fat cells leads to intraosseous hypertension and impaired blood flow within the bone tissue.

Myopathy is caused by the catabolic effect of GCs and occurs in 1-10% of patients. Steroid myopathies are manifested by weakness and atrophy of skeletal muscles. This complication is most often caused by triamcinolone.

GCs can cause gastric ulcers by increasing the secretion of hydrochloric acid and reducing the production of mucus and bicarbonates and inhibiting epithelial regeneration. Steroid ulcers are often asymptomatic or oligosymptomatic, manifesting with bleeding and perforation (frequency less than 1%). This complication is most often caused by prednisolone.

Long-term treatment with GCs may be accompanied by an increase in blood pressure and dystrophic changes in the myocardium. Arterial hypertension is caused by increased sensitivity of the vascular wall to catecholamines, sodium and water retention (frequency 1-10%).

Long-term use of HA can lead to various skin lesions. The most typical are: mild trauma to the skin, deterioration of healing of the wound surface, the appearance of steroid acne on the face, and stretch marks. The development of skin manifestations is associated with the ability of HA to suppress collagen synthesis by skin fibroblasts. The slowdown in tissue regeneration is associated with the anti-anabolic and catabolic effect of GC on protein metabolism - a decrease in the synthesis of proteins from amino acids, and increased protein breakdown.

Damage to the vascular wall with the development of “steroid vasculitis” is often caused by fluorinated GCs (dexamethasone and triamcinolone). Characterized by increased vascular permeability. It manifests itself as hemorrhages in the skin of the forearms, mucous membranes of the oral cavity, conjunctiva of the eyes, and epithelium of the gastrointestinal tract. Increased blood clotting can lead to the formation of blood clots in deep veins and thromboembolism.

Treatment with high doses of GCs can lead to posterior subcapsular cataracts and glaucoma.

Many patients, even those receiving low doses of GCs, may develop increased irritability and insomnia. A very serious complication is steroid psychosis, which develops when high doses of prednisolone are prescribed - more than 30 mg/day.

The immunosuppressive effect of GC leads to an increase in the frequency and severity of infections, an exacerbation of chronic infectious and inflammatory processes occurs, the addition of a secondary infection, tuberculosis, and generalization of local infection (frequency 10%). As a rule, infectious complications are asymptomatic due to the ability of GC to eliminate the clinical manifestations of inflammation.

The most unfavorable consequence of long-term GC therapy is osteoporosis. For example, the risk of osteoporetic fractures in RA patients receiving relatively small doses of GC (on average 8.6 mg/day) reaches 33% over 5 years. The development of osteoporosis is explained by a slowdown in Ca absorption in the gastrointestinal tract, increased synthesis of parathyroid hormone and increased bone resorption, as well as the direct inhibitory effect of GC on osteoblasts.

The risk of side effects, as a rule, increases with increasing dose and duration of GC use (Table 6).

In addition, there is such a peculiar side effect of GCs as withdrawal syndrome, the mechanism of which is not clear. Withdrawal syndrome may occur following rapid drug withdrawal. Anorexia, nausea, lethargy, generalized pain in bones and muscles, and general weakness develop. These symptoms are not associated with hypocortisolism, resemble withdrawal symptoms in drug addicts and are eliminated by resuming GC use. Suppression of the hypothalamic-pituitary-adrenal axis was noted in patients taking even small doses of GCs for several days.

Table 6

Time and conditions for the occurrence of adverse reactions when using glucocorticosteroids

The greatest degree of inhibition of the hypothalamic-pituitary-adrenal system is observed when taking fluorinated GCs - triamcinolone, dexamethasone, betamethasone, which have the longest effect. It is believed that it takes about 12 months to restore normal synthesis of ACTH and endogenous corticosteroids after cessation of treatment. During this period, signs of adrenal insufficiency may develop in stressful situations. In this case, the GC should be prescribed again for a while.

Drugs based on steroid hormones in the treatment of joint diseases are currently one of the leading groups of drugs in terms of their effective therapeutic properties.

Their use for treatment provides significant benefits for the rheumatological patient, which exceed the strength of any non-steroidal anti-inflammatory drugs (NSAIDs). These include: a rapid onset of action and a strong anti-inflammatory effect on the lesion.

However, corticosteroid drugs have not only a positive side, but also a number of quite serious negative consequences, which, in cases of improper prescription and use, can cause significant harm to the patient’s health.

As a result, there is always an ambiguous position of both the patients themselves and doctors towards this. Some are ready to accept them just to eliminate the pain, while others, on the contrary, firmly refuse treatment, since it can cause harm.

Both judgments are incorrect, since corticosteroids or glucocorticoids are simply irreplaceable in some clinical circumstances with a competent approach to treatment. However, there are a number of situations when it is possible to do without them.

What are corticosteroids and their main effects

Corticosteroids or glucocorticoids is a subclass of steroid hormones that are produced exclusively by the adrenal cortex. Unlike other hormones, they are not produced by the gonads. They tend to have glucocorticoid or mineralocorticoid activity to varying degrees.

When glucocorticoid or mineralocorticoid activity predominates, corticosteroids are divided into glucocorticoids and mineralocorticoids. In our case, the main glucocorticoids produced in the human body are cortisone and hydrocortisone.

Also known as corticosteroids are hydrocortisone derivatives that are of semi-synthetic origin, including the following:

• Dexamethasone;
• Prednisolone;
• Methylprednisolone.

From the effects of corticosteroids on the human body, several can be distinguished and presented in the table:

Main indications for the use of corticosteroids

Corticosteroids can be used in the following ways:

1. Systemic – use is prescribed orally, intravenously, intramuscularly;
2. Local – the most common method is intra-articular injections.

Speaking about the use of systemic corticosteroids in the field of rheumatology, the following diseases are direct indications for them:

• Acute rheumatic fever.
• Systemic scleroderma.
• Systemic lupus erythematosus.
• Systemic vasculitis.

The most common use of glucocorticoids is in the form of intra-articular injections for the following diseases of the musculoskeletal system:

• Osteoarthritis.
• Gout.
• Acute traumatic arthritis.
• Synovitis of the knee joint.
• Rheumatoid arthritis.
• Reactive arthritis.
• Periarthritis of the shoulder joint.
• Psoriatic arthritis.

From the list of diseases listed above, the use of corticosteroids is not always indicated. Their prescription is advisable when treatment with NSAIDs for two weeks has not shown positive results. Also, their use occurs in the development of synovitis (inflammation of the synovial membrane of the joint with the formation of effusion in it). This condition in clinical manifestations is expressed by swelling of the joint, limited passive and active movements in the joint.

Contraindications to the use of corticosteroids

As a rule, there are no absolute contraindications to the use of systemic drugs of this type. There are relative restrictions on use, which are:

• Diabetes.
• Ulcerative formations in the stomach and duodenum.
• Heart failure.
• Epilepsy.
• Arterial type hypertension.
• Mental disorders.

The use of corticosteroids by injection into the joint is contraindicated in the following cases of diseases and disorders:

• Local or systemic infectious process;
• Transarticular fracture;
• Severe periarticular osteoporosis;
• Diseases of the blood coagulation system;
• or bone destruction that cannot be corrected.

Side effects of corticosteroids

With systemic use of corticosteroids for a long time, there is a possibility of a large number of unpleasant reactions. Their development must be anticipated before prophylaxis with appropriate drugs is carried out.

The list of adverse reactions from corticosteroids is quite large, among which the main ones are the following:

• Increased body weight;
• Atrophy and
• Stretch marks, hemorrhage and thinning of the skin, acne;
• Osteoporosis and vertebral compression fractures and other pathological fractures manifested against the background of this disease;
• Increased blood pressure;
• Steroid ulcers in the digestive organs;
• Nausea, vomiting, pain in the stomach and esophagus;
• Sleep disorders and psychoses, sudden mood changes;
• Glaucoma, cataract;
• linear growth in children, as well as delayed puberty;
• Increased glucose levels and lipids in the blood.

The manifestation of certain negative consequences (sleep disturbance, emotional instability, etc.) appears immediately after the start of therapy and it is not possible to avoid them. The development of others has a later manifestation and their onset may be limited by using small doses of the hormone, as well as by prescribing medications to prevent the complications caused.