Steroids! The controversy and the facts regarding them
People look at us with big round and fearful eyes the moment we utter the “S” of steroids. In fact a lot of patients start their first consultation with us with the disclaimer “Doctor you won’t give me steroids no?” The first and main reason why a patient would hesitate to go to an Allopathic doctor for rheumatic disease is because there is an ingrained belief that we only prescribe painkillers and steroids. Why is there such a lot of fear in the minds of everyone? There are certain myths surrounding these drugs and we will attempt to address them.
Myth#1: All Allopathy doctors only prescribe steroids and painkillers for Arthritis
Not True! Treatment of Arthritis and various Rheumatic drugs is carried out with Anti Rheumatic drugs called DMARDS (Disease Modifying Anti Rheumatic Drugs). These are neither pain killers nor steroids. In fact in the early stages patient will see no benefit for at least 6-8 weeks and because of this some patients may even feel that the drugs are not working. Hence in the early stages of starting treatment the patient is put on analgesics and even NSAIDS (non- steroidal Anti inflammatory drugs) to buy timetill the DMARDs take effect after which they are weaned off. Sometimes the patient presents himself to us in a significantly disabled state and is unable to even do his activities of daily living such as bathing, going to the toilet etc. In such circumstances, sometimes a small dose of steroids are added to enable the patient to be independent. In such cases however the patient is always informed about the same and the dose clearly given in writing. Once the patient is better the pain killers and the steroids are weaned off. In fact what will alarm you is the fact that a lot of so called Ayurvedic preparations and “Pudi” are laced with liberal amounts of steroids and given to the patients which the patients keep taking because they feel remarkably better with these so called Ayurvedic powders. The moment the effect of these powders wears off the patient again feels very down and gets almost instantaneous relief on taking these powders. Soon the poor unsuspecting patient develops a craving for these powders. Even after developing swelling over the body and face some patients do not even realize that they may be taking steroids.Beware of such Quacks who are masquerading as Ayurvedic practitioners.
Myth # 2: Steroids will harm my Kidneys…
Ha Ha! Steroids do not harm the kidneys. Period! Kidneys can suffer harm with all the painkillers that patient take randomly without the monitoring by a doctor. Sometimes patients just ask a chemist to give them a painkiller and the chemist obliges. This is dangerous and this practice must stop. Having said that what is important to stress here is that the steroids do not harm kidneys at least whatever other side effects they may have.
Controversy : Steroids cause more Harm than Benefit…
Well that depends on who is prescribing them in what dose and for how long. Steroids were meant to be used as life saving drugs. They are meant to be used in a particular dose and a particular fashion and that only in certain situations and diseases. Steroids are drugs which can make a disabled horse win a race and a gasping man live again. However used wrongly these drugs can have significant side effects. Let us address both the facets;benefits and harm in a systematic manner.
a) In a person with severe Rheumatoid arthritis, Antirheumatic drugs will take at least 8 weeks to show benefit. Painkillers can also be given only up to a certain dose beyond which the patient gets Acidity, vomiting, stomach Ulcers, hypertension and even kidney failure. Imagine what this patients reaction will be if we tell him that yes we understand you are in pain but you will need to suffer this pain for another 2 months. What would your reaction be?? This Doc is mad! I can’t bear this pain for another day and he says wait another 8 weeks. In such a patient who cannot even go to the Toilet without support a small dose of steroid can dramatically relieve his pain and buy time till his anti-rheumatic drugs take effect. Thereafter as the patient keeps improving we gradually modify the doses of antirheumatic drugs and taper off the steroids. This is called “Bridge therapy”. It bridges the gap between the disease and the time taken by the antirheumatic drugs to take effect. b) There are certain severe diseases in Rheumatology where the disease needs to be controlled very quickly. If this is not done there can be life threatening consequences. A few examples are Systemic Lupus Erythematosus, Wegeners Granulomatosis, and Dermatomyositis/Polymyositis. There we just do not have time for the antirheumatic drugs to take effect. In these situations the only drugs which will take effect within 24 to 48 hours are steroids. Here Steroids are truly life saving. Over time as the disease modifying drugs take effect again the steroids are gradually tapered off. There have been systematic studies done to study the adverse effects of steroids and how tocounter them so that side effects are minimized and there is maximal benefit derived. c) One of the best studies done so far has shown that if used in doses less than 7.5 mg per day then chances of side effects are reduced significantly. d) Biological drugs are a recent development in the field of Rheumatology and are extremely powerful drugs developed to counter severe rheumatic diseases. The main drawbacks with these drugs are their prohibitive cost and their powerful Immunosuppressive effect.The cost of these medicines is in thousands of rupees per dose. How many people in India do you think can afford these? Obviously only the rich ones and those covered for medical expenses by their employers. Additionally these drugs cause significant suppression of the Immune system. In a country like ours there is a good chance we can develop Infections while on these drugs. Some infections may be minor but some can be major as well such as Pneumonia and tuberculosis etc. Needless to say we can only use these drugs in the higher class who have the money as well as the lifestyle to be able to prevent these infections. Now here is the good part: It has been shown in studies that if antirheumatic drugs are used in combination with low dose steroids then they are almost as good as Biological drugs.
Possible side effects and their prevention
If used for long duration then steroids can cause weakening of bones called Osteoporosis. Additionally they can cause early cataracts and increased pressure in the eye called glaucoma. If taken for long periods then they can cause weight gain, diabetes and high Blood pressure. Sometimes Cholesterol and Triglyceride levels can also rise. All these possible complications need to be monitored by us or your attending Doctor and appropriate steps taken to prevent these from occurring. In conclusion if steroids are used in an appropriate dose and manner in some diseases then they are provide exceptional benefit to the extent of saving lives however used randomly in ill advised doses they can be harmful. Hence these are better handled only by specialists who know how to use them not by all and sundry.