Monday, August 22, 2011

Prednisone: what the *$%! is it doing to me?


This started out as one post that was going to explain the good, the bad and the ugly when it came to corticosteroid therapy. When I realized that it was going to end up being so long that it would induce a narcoleptic state in even my loyalest of readers, I decided to split it up. So here I offer a general explanation of why prednisone has the side-effects it does. I’ve chosen this as an admittedly non-intuitive starting point simply because a lot of questions on this subject have come up recently in LH/LV. (For those unfamiliar with them, LH/LV are online lupus support forums).

Important note:
All corticosteroids drugs work in approximately the same way. This is not to say that there aren’t differences in potency or tolerability, just that the drugs all exploit the same biological pathways. I will be using prednisone as an example because it’s the drug lupus patients are most familiar with, but the same ideas hold true for methylprednisolone, dexamethasone, etc. All of these work by mimicking a natural hormone in the body called cortisol. Although it’s an over-simplification, you can generally assume that prednisone and drugs related to it do all the things cortisol normally does in the body. Sometimes the terms "steroids," "prednisone," and "cortisol" are used almost interchangeably. 

Why take prednisone?
          Prednisone is in some ways very good for lupus patients. This is because it can force all different kinds of cells in the immune system to calm down, and because it takes effect very quickly. Unfortunately, the same properties that allow prednisone to have such a broad power over a kamakazi immune system are the properties that lead to serious side-effects.

So…what causes the side-effects, and why are there so many of them?
            It would be extremely tedious for me to try to list all of the ways prednisone interacts with different body tissues, and probably even more tedious for my readers. So I won’t. But as a broad overview, cortisol (or prednisone) works as a stress hormone. A certain amount of it is made by the body every day, no matter what. It helps keep various systems in balance. However, if someone is really stressed, (s)he starts making more cortisol than normal. This makes sense in theory: if someone is spending his or her day trying to escape from, for example, a pack of hyenas [which I would consider to be stressful], (s)he will need high levels of energy to keep running. So the body kindly starts producing more cortisol, which serves to increase the level of sugar in the blood (allowing for greater energy for the tissues doing the running), breakdown fat molecules (also allowing for more energy), and even increase the levels of muscle breakdown. That last one may sound contradictory, but it’s not. Breaking down a small amount of muscle helps the running-away-from-hyenas goal because the protein coming from the muscle breakdown is converted into, you guessed it, more energy. In this situation, the hyena escapee really isn’t too concerned about his or her long-term muscle status or whether his or her immune system is working well. The priority is to get away from the hyenas, after which the body will stop producing the higher level of cortisol, and rebuild its stores of sugar, skeletal muscle, etc.

            The problem with prednisone, then, is that it works like cortisol, but it’s constantly in the blood, rather than temporarily being spiked for hyena-fleeing purposes. So all of the short-term benefits of cortisol, which are absolutely not designed to be a the body’s status quo, are suddenly present every day, all day. This is bad. People taking prednisone to tone down an autoimmune disease do not want to have their muscles being broken down. Nor do they want their blood sugar levels to go up; that’s useful when running away from hyenas, but not as useful if you’re an insurance agent working in a cubicle. And since (as far as I know) insurance agents don’t run away from hyenas all that often, the prednisone is causing muscle to be broken down for energy, which isn’t being used. So the molecules that represent that energy are turned back into fat, which is dumped in the middle of the body (the trunk, basically), or around the face. So the textbook case of a patient on prednisone shows a person with really skinny arms and legs (because the muscle is being broken down), but large fat deposits around the waist and face.

Sadly, the problems don’t stop there. Prednisone also tells the body to start breaking down your bones for calcium. In healthy people, there’s a balance between bone breakdown and bone formation. As the body needs calcium for other cells, bones are broken down a bit; when the body has enough calcium, the bones are rebuilt. But in a person on prednisone, the balance is broken. Instead of the usual give and take of calcium to and from bones, the “take” switch is always turned on. Again, if your cells need calcium because they’re very active while you’re running away from hyenas, this is fine. It’s a short-term stress response. But prednisone takes that short-term response and draws it out much, much longer than it would generally last in a natural situation. Hence the greatly increased risk of osteoporosis in patients who have frequently been on prednisone.

Tapering vs stopping prednisone therapy cold turkey:
            I won’t go into much detail in this post about tapering, but it is crucial that every patient who takes prednisone for longer than a week understand that it is very, very dangerous to suddenly stop taking prednisone. This is because cortisol is a hormone that the body does not store. It is normally made as needed. So when someone is on prednisone, which for all intents and purposes is the same thing as cortisol, the body goes, “Hey, I’ve got tons of this stuff. I’m not going to waste time or energy making more,” and switches off production altogether. As I mentioned earlier, healthy people do make a certain amount of cortisol every day, and it is very important for keeping various systems in balance. So cutting off prednisone after your body has decided to stop making cortisol is very dangerous. Tapering down slowly allows the body to wake up and say, "Oy, I don't have tons of this stuff anymore, time to get to work making more."

Take-home message:
            Taking prednisone to treat lupus is like using a sledge hammer to put a pin into the wall. It will often accomplish the purpose, but is likely to leave a lot of collateral damage. This is because prednisone mimics cortisol, which is a naturally occurring stress hormone. Because prednisone has such a wide range of activities in the body, a lot of systems that are normally kept in balance go haywire when someone has an unusually high and long-term concentration of the drug in his or her body. In some ways this is good, as it helps switch off the immune system which, in a lupus patient, is trying to kill the rest of the body. But it also has negative side-effects simply because it’s designed to be present in low concentrations, with only occasional spikes to allow for hyena-fleeing or other physically stressful events. I'm not at all saying that one shouldn't take prednisone if a doctor diagnoses it. Sometimes it's the best (or only) way to get lupus under control. But I hope that this article explains why it has the side-effects it does.

Additional Notes:
Image credit: http://www.freebase.com/view/wikipedia/images/commons_id/1325919
Main Information source: Human Physiology: Integrated Approach
My usual disclaimer applies. I am not a physician. I am a lupus patient with bad brain fog, so I make mistakes.. Please do not ever use my explanations as a substitute for talking to your doctor! 

19 comments:

  1. thank you so much sam for your blogs i learn so much from you as you would say geek sam because byou are educated and have the gift noing and being able to get your education doesent make you a geek you are a talented smart great baker who all ways make time to educate us wich is a wonderfull thing considering that v95 percent of dr. have no idea about what there doing thankyou sam for shareing with us and love your bakeing recipies awsome have a question when you get time to blog this ive been on narcotic pain meds for several years strait i have quite few health issues so far my live and kidney are fine i take as little as possible i am drug depended from all the years of use but not a drug addict never take more then i should most of the time i have some left from the last vist long term do you think that my body would shut down if someday i am luckey to get off whats the long term damage from thesee drugs i am on morphine 2 x a day was on fentanal but they wont stick in the summer i sweat to much opiate when you blog this cannyou not use my name as i dont want every one to no i have told some of them aney info would be great thank you sam glad your feeling better

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  2. I'm afraid I'm not quite sure about your question. Are you interested in general long-term side-effects from the narcotics? Or is your concern more the effect of stopping narcotics after being on them for a long time? (Or both)? I'd be happy to look into either (or both) concerns, just let me know if I'm understanding your question(s) correctly.

    I couldn't use your name even if I wanted to, as you didn't leave it. :) But I'm happy to keep the person of anyone asking a question confidential; in fact I think it's often a very good idea to do so. I try to be very careful about writing about narcotics because a lot of lupus patients are on very strong painkillers (legitimately), and it's not very safe for them to let many people know about them. That, plus the fact that there is a stigma attached to painkillers due to the people who abuse them. Those people make me angry, because they can cause people who really need painkillers to be unable to get them.

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  3. Thanks Sam ~ Very informative and entertaining!

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  4. Thanks! I like it when I can feel like the past ten or eleven years of academic work haven't been a total waste of time!

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  5. yes both one is stoping thesee meds after useing for several years 2 long term efects of thesee drugs on my body aney thing else you feel we should no thankyou for takeing time and extra spoon to blog to us on are question also could use some answers on what scerderma doing to my all ready painfull body whats the worst case with sjorgens if your unable to swollow even soft foods is it possible for sjorgens to get so bad that a feeding tube could be neacary yes i no my spelling awfull we love you sam your personality smarts noing your there for us brighten are day we miss you when you dont post i have a question feel free not to answer it if you dont feel comfortable most sinentist dont belive in god may i ask why is that do you belive in god if you dont what makes you want to do good in life if you feel no judgement curious on why they dont belive thank you for youseing one your spoons to answer this crazy question...

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  6. Ok, I'll look into both questions about the painkillers, and I'll look into scleroderma. With Sjogren's syndrome...I've never heard of anyone being put on a feeding tube because of just sjogren's. I am not a physician, so I can't say for sure, but I would imagine that feeding tubes would only really become necessary because of another illness in addition to sjogren's. That's my guess, anyway.

    I don't mind answering the religious questions, either, but I'll warn you that it's not a short answer. :) My background is that I was raised in a very conservative church, which I eventually left because I felt that it was using its power and money to influence politics in a way that I felt was morally wrong. I have since joined the American Episcopal church, which I love. So the short answer is that yes, I do believe in God, and always have.

    The long answer come in when you ask me why I do believe in God. The best answer for why I can give is, of all things, a quote from Sherlock Holmes:

    "There is nothing in which deduction is so necessary as in religion," said he, leaning with his back against the shutters. "It can be built up as an exact science by the reasoner. Our highest assurance of the goodness of Providence seems to me to rest in the flowers. All other things, our powers our desires, our food, are all really necessary for our existence in the first instance. But this rose is an extra. Its smell and its color are an embellishment of life, not a condition of it. It is only goodness which gives extras, and so I say again that we have much to hope from the flowers."

    Or, in other words, I see evidence for God's existence in the things that we have that are not necessary for our own existence. For example, an ability to appreciate the beauties of nature. There is no reason why we biologically have to stand in awe in a redwood forest, but most of us do.

    While I know that many (quite possibly most) scientists are agnostic or atheist, I have to say that there are also many scientists who are religious. I have worked with Catholics, Protestants, Hindus, and people from many other backgrounds. I would say that most of us do tend to lean towards progressive beliefs, rather than a literal interpretation of the old testament (or other religious scriptures). But the core doctrines of any religion, which in my opinion can be summed up as loving God and our neighbors... well, there are an awful lot of us who believe those, even if we don't get as much attention as the rabidly anti-religious scientists.

    (I warned you it would be a long answer!)

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    1. i am interested in the long term efects pain meds have on my body..and after several years of use when stoped ...long term efect on are body you as a sincetist how do you personly feel about them..i enjoy your blogs verry much have learned a lot thankyou for all you do hugs

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    2. I'm sorry, that has been requested before, and I never got around to it. Once I'm home from my current trip I'll get right on it. :)

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  7. Yikes, sorry for the typos in the above comment! I noticed quite a few once I posted the darn thing.

    Also, it may take a while before I can get back to you with the answers to your science questions, just because I'm currently writing a scientific article for work. I'll try to fit it in soon, though.

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  8. Thank you so much Sam for taking the time to share all of your knowledge! I have learned alot from your blogs!!

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  9. sam what is your take on adrenal function after long term pred use? i have been on them 18years now.. wondering if adrenals really shut off forever or if they can return to normal function of course with proper tapering.

    good luck with benlysta btw... i just had #7 on friday myself

    Bernadette

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    1. Okay, I do not know many people who've been on prednisone that long, so I did a little research. Here's one link that is, characteristically vague, but probably accurate. http://www.mayoclinic.com/health/prednisone-withdrawal/AN01624

      As the writer says, it varies from patient to patient. While most patients can, eventually, start producing natural cortisol again, I do not know if there is a point after which the adrenal glands are unable to produce it at all. Sorry to be less than helpful, that's the problem with biology-- is inconsistent between people!

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  10. thanks Sam! i myself couldnt find any definitives... currently i am on 6/7 mg... so i suppose i will find out within the next year i will let you know how it goes

    bernadette

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    1. You are very welcome. It drives me nuts that all the docs and pharmacists do is hand us a list of side-effects. Being a scientist, I always want to know *why* the drug is messing me up! 6/7mg isn't too high a dose, so maybe you'll be ok? I can't tolerate it at any dose (even 5mg!), but that's unusual.

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  11. sorry for late response... just saw this.. anyway to have replies emailed?

    anyways.. 6/7 mg is thanks to benlysta 10 mg was my maintenance dose for years. i have only been able to come off once but not for more than 3 months if that. i have been on as high as pulse steriods but that was in the first year of being diagnosed. anything lower than 5mg since then causes a flare and honestly 5mg isnt that great for me either. so needless to say the closer i get the more i try not to stress about the process. easier said than done! lol i had my hormones tested about a year ago due to hair loss it showed that my dhea levels were low ..the other levels were not an issue. hair loss was contributed to stress from massive shingles attack (i shiver thinking back..sigh) anyhow dhea levels correspond to adrenal function am i correct? if so is it possible to monitor those to see if my adrenals are "waking" up as they should? every where i look it says in order to know if the adrenals work you have to be off prednisone... is this correct? any info and thoughts are appreciated.

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    1. Sorry for the delayed response; I was busy finishing grad school. Yes, DHEA does, to my knowledge, respond to the adrenal glands. As for testing for normal function, I don't know what the standard protocol is. If they are able to decrease your steroids slowly without your body going nuts, then clearly you're starting to make your own cortisol again, which is good. I would imagine that an endocrinologist can test for more detailed information, so it might be worth asking your physician if you should/could see an endocrinologist.

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  12. Dear sam, june of 2013, I was prescribed prednisone for sinus inflammation. I was prescribed a six day course. 10mg for three days and 5mg for three days. Five months later, I am still experiencing symptoms such as depression, frequent awakening, low blood sugar, low stress intolerance, joint pain and a facial rash. Blood serum level was a.m. 7.6 could you please tell me if the tapering was too fast and are my adrenals and pituitary glands permanently suppressed? Thank you in advance for your response. God bless you.

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    1. I'm sorry, I didn't see this before. I can't tell diagnose you, of course, but that seems like a reasonable tapering. I doubt it would have left you permanently suppressed.

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