Corticosteroids (Steroids)

What Is The Difference Between Anabolic Steroids And Corticosteroids?

The term steroids is often misunderstood. Corticosteroids (a class of drugs used to treat arthritis and many other conditions) are often just called "steroids". So what's in a name? Confusion results when they are mistaken for anabolic steroids (drugs used by athletes to boost strength and enhance physical performance). What is the difference between anabolic steroids and corticosteroids?

What is a "Steroid"?

According to NIGMS (National Institute of General Medical Sciences), the term "steroid" is a chemical name for any substance that has a characteristic chemical structure consisting of multiple chemical rings of connected atoms.

Some common examples of steroids include:

… Vitamin D

… cholestrol

… estrogen

… cortisone

Steroids are critical for keeping the body running smoothly. Various steroids have important roles in the body's reproductive system and both the structure and function of membranes.

What are Anabolic Steroids?

According to NIDA (National Institute on Drug Abuse), anabolic steroids are synthetic substances related to the male sex hormones (androgens). They promote growth of skeletal muscle (anabolic effect) and the development of male sexual characteristics (androgenic effects). The proper term for these compounds actually is "anabolic/androgenic" steroids. ìAnabolicî refers to muscle-building, and ìandrogenicî refers to increased masculine characteristics. ìSteroidsî refers to the class of drugs.

Anabolic steroids are available legally only by prescription, to treat conditions that occur when the body produces abnormally low amounts of testosterone, such as delayed puberty and some types of impotence. They are also prescribed to treat body wasting in patients with AIDS and other diseases that result in loss of lean muscle mass.

Anabolic steroids are being abused by some athletes and others to enhance performance or improve physical appearance. Abuse of anabolic steroids can lead to serious health problems, some of which are irreversible. Major side effects can include liver tumors and cancer, jaundice, high blood pressure, kidney tumors, severe acne, and trembling. In males, side effects may include shrinking of the testicles and breast development. In females, side effects may include growth of facial hair, menstrual changes, and deepened voice. In teenagers, growth may be halted prematurely and permanently.

What are Corticosteroids?

Corticosteroids or glucocorticoids, often just called "steroids", are drugs closely related to cortisol, a hormone which is naturally produced in the adrenal cortex (the outer layer of the adrenal gland). Corticosteroids act on the immune system by blocking the production of substances that trigger allergic and inflammatory actions, such as prostaglandins.

Corticosteroid drugs include:

… Betamethasone (Celestone)

… Budesonide (Entocort EC)

… Cortisone (Cortone)

… Dexamethasone (Decadron)

… Hydrocortisone (Cortef)

… Methylprednisolone (Medrol)

… Prednisolone (Prelone)

… Prednisone (Deltasone)

… Triamcinolone (Kenacort, Kenalog)

Corticosteroids (Steroids): Benefits vs. Risks

Corticosteroids are powerful drugs which can quickly reduce swelling and inflammation, greatly improve symptoms and provoke incredible results. However, there are potential consequences and side effects. The power of corticosteroids should not be feared, but must be respected. To maximize benefits, but minimize potential side effects, steroids are usually prescribed in low doses or for short durations. The potent effect of corticosteroids can result in serious side effects which mimic Cushing's disease, a malfunction of the adrenal glands resulting in an overproduction of cortisol. The list of potential side effects is long and can include:

… increased appetite and weight gain

… deposits of fat in chest, face, upper back, and stomach

… water and salt retention leading to swelling and edema

… high blood pressure

… diabetes

… osteoporosis

… cataracts

… acne

… muscle weakness

… thinning of the skin

… increased susceptibility to infection

… stomach ulcers

… psychological problems such as depression

… adrenal suppression and crisis

Side effects are minimized by taking the lowest doses possible (that still yields positive results) and following doctor's orders. It is important to avoid self regulation of the dosage, either by adding more or stopping the drug without a schedule. Steroids must be gradually reduced to permit the adrenal glands to resume natural cortisol production. Eliminating doses too quickly can result in adrenal crisis (a life-threatening state caused by insufficient levels of cortisol). Another possible complication to coming off steroids is withdrawal syndrome, or rebound effect, which is the body's exaggerated response to removal of the drug.

Corticosteroids (Steroids): The Bottom Line

When your treatment plan involves one of the cortcosteroid drugs, especially long-term, you should discuss and weigh the potential benefits versus the potential risks with your doctor.

Examples of corticosteroids used in the pain clinic are:

… Depo-Medrol (methylprednisolone)

… Aristocort (triamcinolone)

… Decadron (dexamethasone)

… Celestone

Depo-Medrol and Aristocort are "depot" medications. This means that they are powders suspended in liquid. They dissolve slowly, working for days to weeks.

Are these the same "steroids" that bodybuilders use?

No. Anabolic steroids used by bodybuilders are completely different medications with different effects.

What are the common side-effects of corticosteroids?

… Flushing or a feeling of warmth

… Some fluid retention

… Menstrual irregularity

… Increased appetite

… Any corticosteroid injection can reduce your resistance to infection, especially viral infections.

… Diabetics can see higher blood sugars for a few days after a corticosteroid injection. They should be careful to check their blood sugars until theyíre back to normal.

Are there serious side-effects from corticosteroids?

Yes. But they are usually seen only with large doses or with long-term daily doses. To lessen the risk of these side effects, the doctors limit the amount and frequency of the corticosteroids they give patients.

Potential side-effects include:

… Psychological disturbance-euphoria, depression, agression

… Osteoporosis (thinning of the bones)-only seen when high doses are received over long periods of time

… Adrenal suppression-suppress the bodyís ability to make cortisol

… Possible side effects of the steroid medications include facial redness, occasional low-grade fevers, hiccups, insomnia, headaches, increased heart rate, and abdominal cramping or bloating. These side effects occur in only about 5% of patients and commonly disappear within 1-3 days after the injection.

More Rare Potential Adverse Reactions:

… Fluid and electrolyte disturbances

- Sodium retention

- Fluid retention

- Congestive heart failure in susceptible patients

- Potassium loss

ß Hypokalemic alkalosis

- Hypertension (high blood pressure)

… Musculoskeletal

- Muscle weakness

- Steroid myopathy

- Loss of muscle mass

- Osteoporosis (loss of bone calcium with weakening of the bones)

- Tendon rupture, particularly of the Achilles tendon

- Vertebral compression fractures

- Aseptic necrosis of the femoral and humeral heads

- Pathologic fractures of long bones

… Gastrointestinal

- Peptic ulcer with subsequent perforation and hemorrhage

- Pancreatitis

- Abdominal distention

- Ulcerative esophagitis

- Mild increases in liver enzymes

… Dermatologic

- Impaired wound healing

- Thin fragile skin

- Petechiae and echimoses

- Facial erythema

- Increased sweating

- May suppress reactions to skin tests

… Neurological

- Convulsions

- Increased intracranial pressure with papilledema (pseudotumor cerebri) usually after treatment

- Vertigo

- Headaches

… Endocrine

- Menstrual irregularities

- Development of cushingoid state

- Suppression of growth in children

- Secondary adrenocortical and pituitary unresponsiveness, particularly in times of stress, as in trauma, surgery or illness.

- Decreased carbohydrate tolerance

- Manifestation of latent diabetes mellitus

- Increased requirements for insulin or oral hypoglycemic agents in diabetes

… Ophtalmic

- Posterior subcapsular cataracts

- Increased intraocular pressure

- Glaucoma

- Exophthalmos

… Metabolic

- Negative nitrogen balance due to protein catabolism

… Adverse reactions reported with spinal or epidural use (extremely rare)

- Arachnoiditis

- Meningitis

- Paraparesis/paraplegia

- Sensory disturbances

- Bowel/bladder dysfunction

- Headaches

- Seizures

- Stroke

… Orthopedic

- Avascular Necrosis of the femoral head

Allergic reactions: Anaphylactoid reaction, anaphylaxis, angioedema.

Cardiovascular: Bradycardia, cardiac arrest, cardiac arrhythmias, cardiac enlargement, circulatory collapse, congestive heart failure, fat embolism, hypertension, hypertrophic cardiomyopathy in premature infants, myocardial rupture following recent myocardial infarction (see WARNINGS, Cardio-renal), edema, pulmonary edema, syncope, tachycardia, thromboembolism, thrombophlebitis, vasculitis.

Dermatologic: Acne, allergic dermatitis, dry scaly skin, ecchymoses and petechiae, erythema, impaired wound healing, increased sweating, rash, striae, suppression of reactions to skin tests, thin fragile skin, thinning scalp hair, urticaria.

Endocrine: Decreased carbohydrate and glucose tolerance, development of cushingoid state, hyperglycemia, glycosuria, hirsutism, hypertrichosis, increased requirements for insulin or oral hypoglycemic agents in diabetes, manifestations of latent diabetes mellitus, menstrual irregularities, secondary adrenocortical and pituitary unresponsiveness (particularly in times of stress, as in trauma, surgery, or illness), suppression of growth in pediatric patients. Steroids will increase the blood sugar levels of diabetics, probably requiring temporary adjustment in medications.

Fluid and electrolyte disturbances: Congestive heart failure in susceptible patients, fluid retention, hypokalemic alkalosis, potassium loss, sodium retention.

Gastrointestinal: Abdominal distention, elevation in serum liver enzyme levels (usually reversible upon discontinuation), hepatomegaly, increased appetite, nausea, pancreatitis, peptic ulcer with possible perforation and hemorrhage, perforation of the small and large intestine (particularly in patients with inflammatory bowel disease), ulcerative esophagitis.

Metabolic: Negative nitrogen balance due to protein catabolism.

Musculoskeletal: Aseptic necrosis of femoral and humeral heads, loss of muscle mass, muscle weakness, osteoporosis, pathologic fracture of long bones, steroid myopathy, tendon rupture, vertebral compression fractures.

Neurological/Psychiatric: Convulsions, depression, emotional instability, euphoria, headache, increased intracranial pressure with papilledema (pseudotumor cerebri) usually following discontinuation of treatment, insomnia, mood swings, neuritis, neuropathy, paresthesia, personality changes, psychic disorders, vertigo.

Ophthalmic: Exophthalmos, glaucoma, increased intraocular pressure, posterior subcapsular cataracts.

Other: Abnormal fat deposits, decreased resistance to infection, hiccups, increased or decreased motility and number of spermatozoa, malaise, moon face, weight gain.

DRUG INTERACTIONS

Aminoglutethimide: Aminoglutethimide may diminish adrenal suppression by corticosteroids.

Amphotericin B injection and potassium-depleting agents: When corticosteroids are administered concomitantly with potassium-depleting agents (e.g., amphotericin B, diuretics), patients should be observed closely for development of hypokalemia. In addition, there have been cases reported in which concomitant use of amphotericin B and hydrocortisone was followed by cardiac enlargement and congestive heart failure.

Antibiotics: Macrolide antibiotics have been reported to cause a significant decrease in corticosteroid clearance (see Drug Interactions, Hepatic Enzyme Inducers, Inhibitors and Substrates).

Anticholinesterases: Concomitant use of anticholinesterase agents and corticosteroids may produce severe weakness in patients with myasthenia gravis. If possible, anticholinesterase agents should be withdrawn at least 24 hours before initiating corticosteroid therapy.

Anticoagulants, oral: Co-administration of corticosteroids and warfarin usually results in inhibition of response to warfarin, although there have been some conflicting reports. Therefore, coagulation indices should be monitored frequently to maintain the desired anticoagulant effect.

Antidiabetics: Because corticosteroids may increase blood glucose concentrations, dosage adjustments of antidiabetic agents may be required.

Antitubercular drugs: Serum concentrations of isoniazid may be decreased. Cholestyramine: Cholestyramine may increase the clearance of corticosteroids. Cyclosporine: Increased activity of both cyclosporine and corticosteroids may occur when the two are used concurrently. Convulsions have been reported with this concurrent use.

Dexamethasone suppression test (DST): False-negative results in the dexamethasone suppression test (DST) in patients being treated with indomethacin have been reported. Thus, results of the DST should be interpreted with caution in these patients.

Digitalis glycosides: Patients on digitalis glycosides may be at increased risk of arrhythmias due to hypokalemia.

Ephedrine: Ephedrine may enhance the metabolic clearance of corticosteroids, resulting in decreased blood levels and lessened physiologic activity, thus requiring an increase in corticosteroid dosage.

Estrogens, including oral contraceptives: Estrogens may decrease the hepatic metabolism of certain corticosteroids, thereby increasing their effect.

Hepatic Enzyme Inducers, Inhibitors and Substrates: Drugs which induce cytochrome P450 3A4 (CYP 3A4) enzyme activity (e.g., barbiturates, phenytoin, carbamazepine, rifampin) may enhance the metabolism of corticosteroids and require that the dosage of the corticosteroid be increased. Drugs which inhibit CYP 3A4 (e.g., ketoconazole, macrolide antibiotics such as erythromycin) have the potential to result in increased plasma concentrations of corticosteroids. Dexamethasone is a moderate inducer of CYP 3A4. Co-administration with other drugs that are metabolized by CYP 3A4 (e.g., indinavir, erythromycin) may increase their clearance, resulting in decreased plasma concentration.

Ketoconazole: Ketoconazole has been reported to decrease the metabolism of certain corticosteroids by up to 60%, leading to increased risk of corticosteroid side effects. In addition, ketoconazole alone can inhibit adrenal corticosteroid synthesis and may cause adrenal insufficiency during corticosteroid withdrawal.

Nonsteroidal anti-inflammatory agents (NSAIDS): Concomitant use of aspirin (or other nonsteroidal antiinflammatory agents) and corticosteroids increases the risk of gastrointestinal side effects. Aspirin should be used cautiously in conjunction with corticosteroids in hypoprothrombinemia. The clearance of salicylates may be increased with concurrent use of corticosteroids.

Phenytoin: In post-marketing experience, there have been reports of both increases and decreases in phenytoin levels with dexamethasone co-administration, leading to alterations in seizure control.

Skin tests: Corticosteroids may suppress reactions to skin tests.

Thalidomide: Co-administration with thalidomide should be employed cautiously, as toxic epidermal necrolysis has been reported with concomitant use.

Vaccines: Patients on corticosteroid therapy may exhibit a diminished response to toxoids and live or inactivated vaccines due to inhibition of antibody response. Corticosteroids may also potentiate the replication of some organisms contained in live attenuated vaccines. Routine administration of vaccines or toxoids should be deferred until corticosteroid therapy is discontinued if possible (see WARNINGS, Infections, Vaccination).

NOTICE:

The information about drugs contained in this website is general in nature and is intended for use as an educational aid. It does not cover all possible uses, actions, precautions, side effects, or interactions of these medicines, nor is the information intended as medical advice for individual problems or for making an evaluation as to the risks and benefits of taking a particular drug. Side effects contained herein, although possible, may be extremely rare. Always consult your physician to assess your particular risks.

Additional Information

Once a medicine has been approved for marketing for a certain use, experience may show that it is also useful for other medical problems. In certain cases this would mean that the medication may not have FDA approval for a certain use, for which your physician may know it to be appropriate. FDA approval for a specific indication is usually given to those drugs for which the parent pharmaceutical company has decided to invest money in conducting efficacy and safety studies, for the use of the medicine on that particular indication. Occasionally, the condition may be rare and the investment to profit ratio for the pharmaceutical may not warrant their interest in pursuing that indication.