Prednisone and other corticosteroids

Weigh the benefits and risks of corticosteroids, such as prednisone, when choosing a medication.

Corticosteroid drugs — including cortisone, hydrocortisone and prednisone — are useful in treating many conditions, such as rashes, lupus and asthma. But these drugs also carry a risk of serious side effects. Working with your doctor, you can take steps to reduce these side effects so that the benefits of corticosteroid treatment outweigh the risks.

How do corticosteroids work?

Corticosteroids mimic the effects of hormones your body produces naturally in your adrenal glands, which are small glands that sit on top of your kidneys. When prescribed in doses that exceed your body’s usual levels, corticosteroids suppress inflammation. This can reduce the signs and symptoms of inflammatory conditions, such as arthritis and asthma.

Corticosteroids also suppress your immune system, which can help control conditions in which your immune system mistakenly attacks its own tissues.

How are corticosteroids used?

Corticosteroid drugs are used to treat rheumatoid arthritis, lupus, asthma, allergies and many other conditions. They also treat Addison’s disease, a condition where the adrenal glands aren’t able to produce even the minimum amount of corticosteroid that the body needs. And these drugs also help suppress the immune system in order to prevent organ rejection in transplant recipients.

You can take corticosteroids:

• By mouth. Tablets, capsules or syrups help treat the inflammation and pain associated with certain chronic conditions, such as rheumatoid arthritis and lupus.
• By inhaler and intranasal spray. These forms help control inflammation associated with asthma and nasal allergies.
• Topically. Creams and ointments can help heal many skin conditions.
• By injection. This form is often used to treat muscle and joint signs and symptoms, such as the pain and inflammation of tendinitis.

What side effects can corticosteroids cause?

Corticosteroids carry a risk of side effects, some of which can cause serious health problems. When you know what side effects are possible, you can take steps to control their impact.

Side effects of oral corticosteroids

Because oral corticosteroids affect your entire body instead of just a particular area, this route of administration is the most likely to cause significant side effects. Side effects depend on the dose of medication you receive and may include:

• Elevated pressure in the eyes (glaucoma)
• Fluid retention, causing swelling in your lower legs
• High blood pressure
• Problems with mood swings, memory and behavior and other psychological effects, such as confusion or delirium
• Weight gain, with fat deposits in your abdomen, face and the back of your neck

When taking oral corticosteroids longer term, you may experience:

• Clouding of the lens in one or both eyes (cataracts)
• High blood sugar, which can trigger or worsen diabetes
• Increased risk of infections, especially with common bacterial, viral and fungal microorganisms
• Thinning bones (osteoporosis) and fractures
• Suppressed adrenal gland hormone production, which may result in a variety of signs and symptoms, including severe fatigue, loss of appetite, nausea and muscle weakness
• Thin skin, bruising and slower wound healing

Side effects of inhaled corticosteroids

When using inhaled corticosteroids, some of the drug may deposit in your mouth and throat instead of making it to your lungs. This can cause:

• Fungal infection in the mouth (oral thrush)
• Hoarseness

If you gargle and rinse your mouth with water — don’t swallow — after each puff on your corticosteroid inhaler, you may be able to avoid mouth and throat irritation. Some researchers have speculated that inhaled corticosteroid drugs may slow growth rates in children who use them for asthma.

Side effects of topical corticosteroids

Topical corticosteroids can lead to thin skin, red skin lesions and acne.

Side effects of injected corticosteroids

Injected corticosteroids can cause temporary side effects near the site of the injection, including skin thinning, loss of color in the skin, and intense pain — also known as post-injection flare. Other signs and symptoms may include facial flushing, insomnia and high blood sugar. Doctors usually limit corticosteroid injections to three or four a year, depending on each patient’s situation.

Reduce your risk of corticosteroid side effects

To get the most benefit from corticosteroid medications with the least amount of risk:

• Try lower doses or intermittent dosing. Newer forms of corticosteroids come in various strengths and lengths of action. Ask your doctor about using low-dose, short-term medications or taking oral corticosteroids every other day instead of daily.
• Switch to nonoral forms of corticosteroids. Inhaled corticosteroids for asthma, for example, reach lung surfaces directly, reducing the rest of your body’s exposure to them and leading to fewer side effects.
• Make healthy choices during therapy. When you’re taking corticosteroid medications for a long time, talk with your doctor about ways to minimize side effects. Eat a healthy diet and participate in activities that help you maintain a healthy weight and strengthen bones and muscles.
• Consider taking calcium and vitamin D supplements. Long-term corticosteroid therapy may cause thinning bones (osteoporosis). Talk with your doctor about taking calcium and vitamin D supplements to help protect your bones.
• Take care when discontinuing therapy. If you take oral corticosteroids for a long time, your adrenal glands may produce less of their natural steroid hormones. To give your adrenal glands time to recover this function, your doctor may reduce your dosage gradually. If the dosage is reduced too quickly, your adrenal glands may not have time to recover and you may experience fatigue, body aches and lightheadedness.
• Wear a medical alert bracelet. This or similar identification is recommended if you’ve been using corticosteroids for a long time.
• Get regular checkups. If you’re taking long-term corticosteroid therapy, see your doctor regularly to check for side effects.

Weigh the risks and benefits of corticosteroids

Corticosteroids may cause a range of side effects. But they may also relieve the inflammation, pain and discomfort of many different diseases and conditions. If you work with your doctor to make choices that minimize side effects, you may achieve significant benefits with a reduced risk of such problems.

The evidence is in. WHO says corticosteroids really do save lives of people critically ill with COVID-19

Readily available drugs, which dampen the runaway inflammatory response in patients severely ill with COVID-19, save lives, according to evidence released this week.

An analysis by the World Health Organisation (WHO), which drew together results from several studies, confirms the benefit of this group of anti-inflammatory steroid drugs, known as corticosteroids.

While earlier studies showed the apparent benefit of one of these drugs, dexamethasone, this latest evidence goes further.

It shows other cheap and readily available corticosteroid drugs, including hydrocortisone, could benefit patients at the life-threatening stages of coronavirus infection.

Remind me again, what are corticosteroids?

Corticosteroids have been used for decades to treat a variety of inflammatory conditions. These include severe forms of lung inflammation, such as pneumonia, shock due to infection, and severe respiratory syndromes. They are also used to treat more common conditions, including asthma and eczema.

These medicines are on the WHO list of essential medicines, meaning they are widely available (usually at low cost).

What do we already know about corticosteroids for COVID-19?

In June, early release of results from the RECOVERY trial showed dexamethasone reduced the risk of death by up to a third in people hospitalised with COVID-19 who needed a ventilator to help them breathe.

Despite the early release of the trial results, and limited details at the time, the findings were compelling and clinical practice changed.

Several other trials were stopped. All patients switched to receive active treatment with a corticosteroid.

The results of the RECOVERY trial have since been formally peer reviewed and published.

What does the latest evidence say?

The WHO drew together results from seven randomised clinical trials, including data from 1,703 critically ill patients with COVID-19.

This is a powerful and compelling way to combine information and truly address the question of whether these medicines benefit people in hospital critically unwell with COVID-19.

The study, which included patients from Australia and New Zealand, found almost 33% of people treated with corticosteroids died within 28 days of treatment. This was compared with 41% of patients who received supportive care (or placebo). Corticosteroid treatment helped patients whether or not they needed ventilation or oxygen.

Importantly, the analysis also concluded the benefits were not specific to one corticosteroid drug but were the same for dexamethasone and hydrocortisone.

Corticosteroids can also have an impact on the immune system. So the researchers looked at the risk of infection from other causes, for example bacterial pneumonia, and found it was not a major concern.

What does this mean for patients?

The weight of evidence has led WHO guidelines this week to strongly recommend using corticosteroids to treat people with severe or critical COVID-19.

This aligns with current Australian guidelines for treating hospitalised patients with COVID-19 needing oxygen support.

Corticosteroids are not for everyone and are not a cure

It is important to remember these findings only apply to using corticosteroids in critically ill people hospitalised with COVID-19. There is currently limited information to suggest these medicines are appropriate for people with mild COVID-19.

While corticosteroids help treat the body’s response to the coronavirus infection, they are not antiviral drugs. They do not inhibit the virus itself, so they are not a cure.

A new way of doing research

Usually, several clinical trials on a common theme are published over a series of years. Then a meta-analysis draws together their results, publishing these combined results much later.

But the amazing thing about this latest evidence is the meta-analysis included data from clinical trials published at the same time. This shows a degree of co-operation and collaboration between researchers to share data to urgently address important research questions that guide clinical care.

Evidence to guide the best treatments and management for people with COVID-19 continues to emerge. You can follow the evidence and how it’s applied in Australia here.