While steroid dosage should be kept at the lowest effective level, steroids must not be stopped suddenly if they have been taken for more than four weeks. After that time, some shrinking of the adrenal glands will occur, and they may not produce enough cortisone if the synthetic steroids are discontinued abruptly. A slow reduction in the dosage of steroids allows the adrenal glands to regain their ability to manufacture natural cortisone. Prednisone and other steroids should not be stopped suddenly. Lupus patients should discuss the reasons for using steroids and other treatment alternatives which may be available with their physician.

PREDNISONE

Steroids produced by the outer part (cortex) of the adrenal gland are called "corticosteroids." Prednisone is the synthetic corticosteroid preparation most often used in the treatment of lupus. It comes in tablets of 1, 5, 10, and 20 miligrams (mg). It may be given as often as four times each day, as infrequently as one every other day, or at any frequency in between. Less than 10 mg per day is generally considered a low dose; 11 to 40 mg is a moderate dose; and 41 to 100 mg daily is a high dose.

Steroids may also be given by intra-muscular injection or may be injected directly into a joint. Occasionally, very large doses of steroids may be given for a short period of time. This treatment, referred to as ";pulse steroid treatment," involves giving 1000 mg of methyl-prednisone IV each day for three days.

Prednisone is an extremely effective drug and may be necessary to control active lupus. Although many lupus patients do not need to stay on steroids continuously, those with severe disease or active and serious kidney lupus may require long-term steroid treatment.

There is usually prompt relief of most symptoms after initiation of treatment with corticosteroids. When pleurisy or pericarditis occur, small or moderate doses of steroids are helpful. Steroids can often be avoided completely in mild cases of lupus.

In additiona to prednisone some other cortisone derivatives include hydrocortisone, methyloprednisolone and dexamethasone.

SIDE EFFECTS

Some of the more common side effects of steroids include changes in appearance, such as acne, development of a round or moon-shaped face, and an increased appetite leading to weight gain. Steroids may also cause a redistribution of fat, leading to a swollen face and abdomen, but thin arms and legs. In some cases, the skin becoms more fragile, which leads to easy bruising.

Psychological side effects of steroids include irritability, agitation, euphoria or depression. Insomnia can also be a side effect. These changes in appearance and mood are often more apparent with high doses of steroids.

An increase in susceptibility to infections may occur with high doses of steroids. Prednisone may also aggravate diabetes, glaucoma, and high blood pressure, and often increaes cholesterol and triglyceride levels in the blood. In children, steroids can suppress growth.

SIDE EFFECTS FROM LONG TERM USE OF STEROIDS

Side effects that may be caused by the long-term use of steroids include cataracts, muscle weakness, avascular necrosis of bone and osteoporosis.

Avascular necrosis of bone, usually associated with high doses of prednisone over long periods of time, produces pain, an abnormal bone scan, and an a typical xray appearance. It occurs most often in the hip, but it can also affect the shoulders, knees and other joints. Avascular necrosis of bone is quite painful and often requires either a core bone biopsy, electrical stimulation, or total surgical joint replacement for pain relief.

Steroids reduce calcium absorption through the gastrointestinal tract which may result in osteoporosis, or thinning of the bones. Osteoporosis can lead to bone fractures, especially compression fractures of the vertebrae, causing severe back pain. Giving calcium and other medications may help to prevent osteoporosis.

There is also a relationship between steroids and premature arteriosclerosis, which is a narrowing of the blood vessels by fat deposits.

In general, there is a close relationship between the side effects of steroids and the dose and duration of their use. Thus, a high dose of steroids given over a long period of time is more likely to cause side effects than a lower dosage given over a shorter period of time.

Corticosteroids are extremely effective anti-inflammatory agents can be very helpful in treating active lupus, despite their significant side effects. Treatment with steroids should always be kept at the lowest possible effetive dose and should not be stopped suddenly. Hopefully, we will soon develop effective altenrative therapies which will not be as toxic as steroids. The history of most therapies shows, however, that those which are extremely effective often are associated with side effects. There is certainly the case with steroids.

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