“We are just wanting to know if we need to start steroids.”
Doctors will often make this comment when seeking out a rheumatology consultation. Prednisone has almost become synonymous with rheumatology. For years it was one of just a handful of treatments at our disposal to calm down the myriad of autoimmune and inflammatory conditions we came across. But the liberal use of prednisone by rheumatologists also served as education to all the harms the drug can cause.
When facing a prescription for prednisone, one can have many mixed feelings. Relief at the prospect of having some respite from pain and fear at the idea of all the side effects. Prednisone use has become so ubiquitous, especially with autoimmune disease, it can be easy to think of it as simply another “Tylenol” or “Advil.” But it needs to be understood and respected in order to be best used.
What is Prednisone?
Prednisone is simply a synthetic glucocorticoid. The adrenal glads produce glucocorticoids, a type of corticosteroid. It is a step in the intricate and delicate system that starts in the hypothalamus (the brain), goes through the pituitary gland and then results in the adrenal gland’s release of cortisol, the body’s home-made glucocorticoid. This pathway, the HPA axis (hypothalamic-pituitary-adrenal axis), is involved in EVERYTHING. Almost any human body function you can think of, the HPA axis has a hand in it. The release (or lack thereof) of cortisol dictates and responds to multiple triggers in the body and environment.
Cortisol is natural-made and prednisone is pharmaceutical made. And it isn’t the only one. There are multiple formulations of synthetic cortisol, all with different properties that make them useful for different circumstances. There are creams, pills, injectables, infusion-able and inhaled versions of synthetic cortisol. Rheumatologist most commonly prescribe prednisone, methylprednisolone and hydrocortisone.
When do we need prednisone?
As almost every system in the body utilizes cortisol, synthetic cortisol, or prednisone (which I will use to mean any oral synthetic glucocorticoid) can have many effects. We use prednisone when out-of-control inflammation needs to be calmed down. This isn’t specific for any particular condition and doctors across multiple specialties use prednisone. It is used in asthma, cancer, sepsis, sinus infections and autoimmune disease. Any time there is raging inflammation – prednisone comes to the rescue!
The conditions most likely to need long-term use are the autoimmune conditions, such as lupus, RA, AS, Sjogren’s. But long term-use isn’t our goal anymore, even in these conditions. These days, rheumatologists take (or should take) a much more targeted approach when using prednisone.
How do Rheumatologists use it?
No one likes prednisone. No one wants to be on prednisone and most rheumatologists don’t love prescribing it. But there are circumstances where it is not only useful but necessary. It is helpful to think of prednisone as both a rope and a bridge. It’s a rope we use to pull someone off the “inflammatory cliff.” When one has a flare of their autoimmune, especially a very serious one, out of control inflammation can wreak havoc on their organs. To date, there is nothing as fast and effective at calming that inflammation as prednisone.
Once someone is off that cliff and is more stable, we will then use prednisone as a bridge to get them to safer maintenance medication. Prednisone’s effective anti-inflammatory action comes at a high price when used long-term. When faced with a chronic autoimmune condition, the key is finding the right medication (or other intervention) that will keep inflammation at bay without the side effects of prednisone. In rheumatology, we luckily have more medications to choose from than ever before, but most take time to take effect. Instead of leaving someone at risk for a flare, we can use prednisone as a bridge.
How do I get off this?
It is just as important to understand how to come off prednisone as it is to understand how to use it. Taking prednisone longer than a few weeks requires a taper and should be done under the guidance of your doctor. Remember that HPA axis? When taking prednisone (or it’s equivalent) the adrenal glands stop producing their own cortisol, as they sense they don’t have to (you are taking synthetic cortisol, after all). If you abruptly stop taking that synthetic cortisol, your adrenal glands can often not respond quickly enough to start making their own. This results in either in mild symptoms of fatigue or severe symptoms of low blood pressure or even death. Tapering the prednisone down slowly allows the adrenals time to sense the decreased cortisol and “wake up.”
Taking or relying on prednisone can be frustrating. It can come with a host of unpleasant side effects. But you should always come off with the guidance of your doctor as stopping too quickly can also cause problems.