1. Steroids: Friend or Foe? By Debbie LaFerney

2. Are steroid shots beneficial for healing and pain relief? Are there any concerns about corticosteroid injections? Are they safe? The short answer is that corticosteroids decrease inflammation and swelling which decreases pain. This decrease in pain can promote earlier mobilization which can be very helpful. However, removing the protective mechanism of pain can result in overstressing the tissues. Interrupting the inflammatory process could lead to weakened tissues and delayed healing. Decreased inflammation slows down the function of fibroblasts which produce collagen and macrophages that eliminate foreign substances.(1) Care must be taken with long-term usage as steroids have a long list of side effects.

3. Using steroids in later stages of healing as in areas of chronic inflammation is questionable. Excessive use decreases the effectiveness of the immune system and can mask other disease processes like infection.(1) However, a more complete answer is more complicated and requires a review of what steroids are, how they are used and how they work.

4. What are steroids? Steroids are hormones produced by the adrenal cortex. There are two types of adrenal steroids: glucocorticoids and mineralocorticoids. Sex hormones are also produced by the adrenal cortex (as well as the gonads).(2)

5. Two types of steroid therapy Replacement therapy is for the replacement of deficient hormone levels with a goal of bringing the levels back up to a physiologic dose to make for the deficiencies. Higher pharmacologic doses are used to have an increased effect beyond normal levels. Therapeutic use tries to get a balance of the levels to capture the needed effects while minimizing the undesired effects.(2)

6. Glucocorticoids Glucocorticoids are primarily involved in the control of glucose metabolism and the body’s ability to deal with stress. They can also decrease inflammation and suppress the immune system.(2) The primary glucocorticoid released in humans is cortisol. It’s secretion is controlled by hypothalamic and pituitary hormones. Cortisol usually follows a circadian rhythm of a slow rise in the morning (peaking at 8 a.m.) to prepare you for increased activity. It is released following any stressful stimulus (real or imagined) such as trauma, infection, hemorrhage, temperature extremes, food or water deprivation and/or any perceived psychological stress.(3)

7. What do they do? Steroids alter protein synthesis in responsive cells by having a direct effect on the cell’s nucleus. They alter the transcription of specific DNA genes which changes the RNA synthesis of cellular proteins of target cells which can turn off the pro- inflammatory genes to suppress inflammation. This effect can take hours or days to reach a high enough concentration of altered proteins. Some effects such as altering the cell membrane are almost immediate such as with psychological stress responses.(2)

8. When glucocorticoids suppress inflammation they also effect macrophages, lymphocytes and endothelial cells which then suppresses the immune system. They effect cardiac output by changing vascular permeability causing vasoconstriction. They effect renal function by impairing the kidney’s ability to excrete water by enhancing sodium reabsorption. Too high or too low levels of glucocorticoids effect the CNS function exhibiting mood and/or behavior changes.(2)

9. Cortisol The most plentiful glucocorticoid is cortisol. It increases blood glucose and liver glycogen. It does this by breaking down muscle into amino acids and fats into fatty acids which are transported to the liver for gluconeogenesis. There it can be stored as glycogen or released into the circulatory system to increase blood glucose levels. Cortisol inhibits the uptake of glucose causing the blood levels to stay high for increased energy for increased activity. However, the increased energy is at the expense of muscle breakdown. So long term use of steroids can result in excessive muscle (skeletal or cardiac) catabolism.(2)

10. Mineralocorticoids Minerlocorticoids maintain fluid and electrolyte (especially sodium and potassium) balance. By causing vasoconstriction of peripheral vessels they help maintain blood pressure. Prolonged use can lead to cardiac hypertrophy and fibrosis, hypertension, peripheral edema and detrimental changes to cardiac tissues.(2)

11. How are they used? Glucocorticoids can be swallowed, applied topically, used in eye drops, inhaled or injected. Injections are used to treat localized areas versus treating systemically. The injections can be into a muscle or a joint space. Injections are usually limited to four or less per year to minimize the breakdown of surrounding muscle and/or tendon. Steroids are used to treat symptoms but do not cure the underlying problem. The underlying problem/disease may instead worsen. Glucocorticoids are extremely helpful and can be lifesaving with short term use to control severe inflammation and allergic responses. Long term use of steroids is not to be stopped abruptly as the body can not immediately resume production of glucocorticoids.(2)

12. Too much of a good thing Prolonged use of glucocorticoids can result in the breakdown of muscle, bone, ligament, tendon and skin. It can also result in Cushing syndrome with symptoms of round face, puffiness, fat deposits in the trunk, muscle wasting, hypertension, osteoporosis, increased body hair and glucose intolerance.

13. So your patient is on steroids Patients who are frequently treated with steroids long term include those with rheumatoid arthritis, ankylosing spondylitis and lupus. Treatment of long term use patients should include strengthening and weight-bearing activities as well as ambulation but avoid over stressing weakened tissues. Bone loss should be monitored and treated if necessary. Other side effects can include peptic ulcers due to protein breakdown of the stomach wall. They may cause growth retardation in children. They may cause cataract formation from impaired fluid drainage of the eye. Patients should be monitored for mood changes and even psychosis. Blood pressure should be monitored for hypertension. Blood sugar should be monitored for insulin resistance and decreased control of blood glucose levels. Patients should be monitored for skin breakdown. Sources of possible infection should be avoided.(2) Since glucocorticoids stimulate the appetite with a craving for high calorie fatty or sweet foods, their weight should be monitored.(3) The effects of long term use can be even greater with inactivity, poor nutrition and the effects of aging.(2)

14. A quick review Glucocorticoids regulate the body’s immune response by regulating carbohydrate, lipid and protein metabolism. Indications include asthma, advanced TB, pericarditis, acute and chronic inflammation, adrenal insufficiency, to stop preterm labor, hypercalcemia, cerebral edema, acute spinal cord injury, MS or shock. Adverse reactions include a catabolic effect on muscle, bone, ligament and/or tendon; suppression of the hypothalamic-pituitary-adrenal pathway and/or Cushingoid syndrome with long term use. Other effects can include euphoria, insomnia, psychotic behavior, pseudotumor, mental changes, nervousness, restlessness, heart failure, hypertension, edema, acute tendon ruptures and/or delayed wound healing. Withdrawal symptoms of drugs stopped abruptly could include fever, myalgias, arthralgias, malaise, nausea, orthostatic hypotension, dizziness, fainting, dyspnea and/or hypoglycemia.

15. Mineralocorticoids regulate electrolyte homeostasis. Indications include adrenal insufficiency and/or orthostatic hypotension in diabetics. Adverse reactions include salt and water retension, cardiac hypertrophy, edema, heart failure, bruising, diaphoresis, hives, allergic rash and/or hypokalemia. All adrenocorticoid drugs have both glucocorticoid and mineralocorticoid properties to some extent.(4)

16. Reference List 1. Magee D, Zachazewski J, Quillen W. Scientific Foundations and Principles of Practice in Musculoskeletal Rehabilitation. 1 st ed. St.Louis, MO: Elsevier:2007:18-244. 2. Coccone C. Pharmacology in Rehabilitation. 4 th ed. Philadelphia, PA: Davis;2007:415-430. 3. Zerwekh J, Claborn J, Gaglione T, et al. Mosby’s Pharmacology Memory NoteCards. 3 rd ed. St. Louis, MO: Elsevier; 2012:100. 4. Rodda B, Tinsley S. Quick Study Pharmacology. 1 st ed. BarCharts; 2006:2.