Prednisolone and its relatives are the most effective anti-inflammatory drugs available. They also carry the widest range of side effects of anything used in rheumatology. Both things are true at once, and the way they are prescribed reflects that.
What they are for
Steroids are used in three situations.
- As a bridge. Disease-modifying drugs take weeks to months to work. A steroid controls symptoms in the meantime and is then withdrawn.
- For a flare. A short course brings a flare under control quickly.
- As the main treatment, briefly, in serious disease. In giant cell arteritis, severe lupus or vasculitis affecting an organ, a high dose is started immediately, sometimes before the diagnosis is confirmed, because delay costs sight or kidney function.
Why the dose comes down
Steroid side effects depend on how much and for how long. At low doses over short periods they are minor. Over months and years, and at higher doses, they accumulate: weight gain, raised blood sugar, raised blood pressure, thinning of the bones, cataracts, skin thinning and increased susceptibility to infection.
None of that is a reason to refuse a steroid when it is needed. It is the reason the plan always includes coming off it. The lowest dose that holds the disease, for the shortest time that does the job, is the goal from the first prescription.
If you find yourself unable to reduce below a certain dose without symptoms returning, that is important information: it usually means the underlying treatment needs changing rather than that the steroid should continue.
Why it cannot be stopped suddenly
The body makes its own steroid hormone. When a steroid is taken for more than a few weeks, that natural production quietens down. If the tablets stop abruptly, the body is left with neither, and the result — profound fatigue, nausea, low blood pressure, and in severe cases collapse — can be dangerous.
A taper gives natural production time to recover. Follow the reducing schedule exactly as written, and if you are unsure what the next step is, ask rather than guessing.
Protecting the bones
Anyone expected to take a steroid for three months or more should have bone protection considered from the start. That usually means adequate calcium and vitamin D, and in many cases a bone-protecting medicine. Waiting until a fracture happens is far too late — the bone loss from steroids is fastest in the first six months.
What to watch for
- Blood sugar, particularly if you have diabetes or a family history of it. Steroids raise it, sometimes considerably.
- Blood pressure and ankle swelling.
- Infection. Steroids blunt the usual signs, so an infection can be advanced before it feels serious. Fever while on a steroid deserves prompt attention.
- Mood and sleep. Higher doses often disturb sleep and can affect mood. This settles as the dose comes down.
Carry the information with you
If you are on a steroid, keep a note of it in your wallet or on your phone, and tell any doctor or dentist who treats you. If you are admitted to hospital, are unable to keep tablets down, or have a serious infection or injury, the dose may need to be temporarily increased rather than stopped — the opposite of what people often assume.
The balance
Used well, steroids are among the most valuable drugs in medicine. Used indefinitely without a plan, they cause avoidable harm. Every prescription should come with an answer to a single question: what is the plan for coming off this, and what takes over when it does?
This article is general information and does not replace a consultation.