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Crohn's Disease Forum » Treatment » Prednisone/Entocort » Overview of Corticosteroids


12-02-2011, 04:44 PM   #1
DustyKat
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Overview of Corticosteroids

Corticosteroids

Corticosteroids (for example, prednisone, prednisolone, hydrocortisone, etc.) have been used for many years to treat patients with moderate to severe Crohn's disease and ulcerative colitis and to treat patients who fail to respond to 5-ASA. Unlike 5-ASA, corticosteroids do not require direct contact with the inflamed intestinal tissues to be effective.

Oral corticosteroids are potent anti-inflammatory medications. After absorption, corticosteroids exert prompt anti-inflammatory actions throughout the body, including the intestines. Consequently, they are used in treating Crohn's disease anywhere in the small intestine, as well as ulcerative and Crohn's colitis. In critically ill patients, intravenous corticosteroids (such as hydrocortisone) can be given in the hospital. For patients with proctitis, hydrocortisone enemas (Cortenema) can be used to deliver the corticosteroid directly to the inflamed tissue. By using the corticosteroid topically, less of it is absorbed into the body and the frequency and severity of side effects are lessened (but not eliminated) as compared with systemic corticosteroids.

Corticosteroids are faster-acting than 5-ASA, and patients frequently experience improvement in their symptoms within days of beginning them. Corticosteroids, however, do not appear to be useful in maintaining remission in Crohn's disease and ulcerative colitis or in preventing the return of Crohn's disease after surgery.

Side effects of corticosteroids

The frequency and severity of side effects of corticosteroids depend on the dose and duration of their use. Short courses of corticosteroids, for example, usually are well-tolerated with few and mild side effects. Long-term use of high doses of corticosteroids usually produces predictable and potentially serious side effects. Common side effects include:

rounding of the face (moon face),

acne,

increased body hair,

diabetes,

weight gain,

high blood pressure,

cataracts,

glaucoma,

increased susceptibility to infections,

muscle weakness,

depression,

insomnia,

mood swings,

personality changes,

irritability, and

thinning of the bones (osteoporosis) with fractures of the spine.
Children receiving corticosteroids experience stunted growth.

The most serious complication from long term corticosteroid use is aseptic necrosis of the hip joints. Aseptic necrosis is a condition in which there is death and degeneration of the hip bone. It is a painful condition that can ultimately lead to the need for surgical replacement of the hip. Aseptic necrosis also has been reported in the knee joints. It is not known how corticosteroids cause aseptic necrosis. The estimated incidence of aseptic necrosis among corticosteroid users is 3% to 4%. Patients on corticosteroids who develop pain in the hips or knees should report the pain to their doctors promptly. Early diagnosis of aseptic necrosis with cessation of corticosteroids might decrease the severity of the aseptic necrosis and the need for hip replacement surgery.

Prolonged use of corticosteroids can depress the ability of the body's adrenal glands to produce cortisol (a natural corticosteroid necessary for proper functioning of the body). Therefore, abruptly discontinuing corticosteroids can cause symptoms due to a lack of natural cortisol (a condition called adrenal insufficiency). Symptoms of adrenal insufficiency include nausea, vomiting, and even shock. Withdrawing corticosteroids too quickly also can produce symptoms of joint pain, fever, and malaise. Therefore, when corticosteroids are discontinued, the dose usually is tapered gradually rather than stopped abruptly.

Even after corticosteroids are discontinued, the adrenal glands' ability to produce cortisol can remain depressed from months up to two years. The depressed adrenal glands may not be able to produce increased amounts of cortisol to help the body handle the stress of accidents, surgery, and infections. Therefore, patients need additional corticosteroids during stressful situations to avoid developing adrenal insufficiency. Because corticosteroids are not useful in maintaining remission in ulcerative colitis and Crohn's disease, and because they have predictable and potentially serious side effects, they should be used for the shortest possible length of time.

Proper use of corticosteroids

Once the decision is made to use systemic corticosteroids, treatment usually is initiated with prednisone, 40-60 mg daily. The majority of patients with Crohn's disease respond with an improvement in symptoms within a few weeks. Once symptoms have improved, prednisone is reduced by 5-10 mg per week until a dose of 20 mg per day is reached. The dose then is reduced at a slower rate until the corticosteroid is discontinued. Gradually reducing corticosteroids not only minimizes the symptoms of adrenal insufficiency, it also reduces the chances of an abrupt recurrence of inflammation.

Many doctors use 5-ASA compounds and corticosteroids together. In patients who achieve remission with corticosteroids, 5-ASA compounds often are continued alone to maintain remission.

In patients whose symptoms return while corticosteroids are slowly being reduced, the dose of corticosteroids is increased slightly to control the symptoms. Once the symptoms are under control, the reduction of corticosteroids can resume at a slower pace. Unfortunately, many patients who require corticosteroids to induce remissions become corticosteroid dependent, (especially individuals who smoke and have disease of the colon). These patients consistently develop symptoms whenever the corticosteroid dose falls below a certain level. In such patients who are corticosteroid dependent as well as in patients who are unresponsive to corticosteroids and other anti-inflammatory medications, immuno-modulator medications, or surgery must be considered. The management of patients who are corticosteroid dependent or patients with severe disease that responds poorly to medications is complex. Doctors who are experienced in treating ulcerative colitis and Crohn's disease and in using immuno-modulators should evaluate these patients.

Prevention of osteoporosis

Long-term use of corticosteroids can cause osteoporosis. Calcium is very important in the formation and maintenance of healthy bones. Corticosteroids decrease the absorption of calcium from the intestine and increase the loss of calcium from the kidneys. Increasing dietary calcium intake is important but alone cannot halt corticosteroid-induced osteoporosis. To prevent or minimize osteoporosis, management of patients on long-term corticosteroids should include:

Adequate intake of calcium (1000 mg daily in premenopausal women, 1,500 mg daily in postmenopausal women) and vitamin D (800 units daily).

Periodic review with the doctor of the need for continued corticosteroid treatment and use of the lowest effective dose if continued treatment is necessary.

For patients taking corticosteroids for more than three months, a bone density study may be helpful in determining the extent of bone loss and the need for more aggressive treatment.

Regular weight-bearing exercise and stopping smoking (cigarettes).

Discussion with the doctor regarding the use of alendronate (Fosamax), risedronate (Actonel), or etidronate (Didronel) to prevent or treat corticosteroid-induced osteoporosis.

http://www.medicinenet.com/crohns_disease/page7.htm

Budesonide (Entocort EC)

Budesonide (Entocort EC) is a newer type of corticosteroid for treating Crohn's disease. Like other corticosteroids, budesonide is a potent anti-inflammatory medication. Unlike other corticosteroids, however, budesonide acts only via direct contact with the inflamed tissues (topically) and not systemically. As soon as budesonide is absorbed into the body, the liver converts it into inactive chemicals. Therefore, for effective treatment of Crohn's disease, budesonide, like topical 5-ASA, must be brought into direct contact with the inflamed intestinal tissue.

Budesonide capsules contain granules that allow a slow release of the drug into the ileum and the colon. In a double-blind multicenter study (published in 1998), 182 patients with Crohn's ileitis and/or Crohn's disease of the right colon were treated with either budesonide (9 mg daily) or Pentasa (2 grams twice daily). Budesonide was more effective than Pentasa in inducing remissions while the side effects were similar to Pentasa. In another study comparing the effectiveness of budesonide with corticosteroids, budesonide was not better than corticosteroids in treating Crohn's disease but had fewer side effects.

Because budesonide is broken down by the liver into inactive chemicals, it has fewer side effects than systemic corticosteroids. It also suppresses the adrenal glands less than systemic corticosteroids. Budesonide also is available as an enema for the treatment of proctitis.

Budesonide has not been shown to be effective in maintaining remission in patients with Crohn's disease. If used long-term, budesonide also may cause some of the same side effects as corticosteroids. Because of this, the use of budesonide should be limited to short-term treatment for inducing remission. As most budesonide is released in the terminal ileum, it will have its best results in Crohn's disease limited to the terminal ileum.

It is not known whether budesonide is effective in treating patients with ulcerative colitis, and it is currently not recommended for the treatment of ulcerative colitis.

http://www.medicinenet.com/crohns_disease/page8.htm

Dusty.
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03-21-2012, 08:38 AM   #2
Paul Cronk
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Your overview is very helpful and well researched. My "moderate" Crohn's (I call it that because no irreversible tissue damage to date) is usually controlled by Pentasa daily 4g (at first it was 2g) but lately a flare occurs about every six weeks and has to be controlled by Prednisone 20mg 2 weeks (tailing off in the last week).

My doc wants me to try a permanent low dose of Pred. This is preferred to Budenisode because I have Arthritic symptoms as well, which the Pred will also address. My questions to all who may read this is are:

1. Can I expect to avoid major side effects at this dosage (I am very fit and active when well which helps). Moon cheeks are just not on for me.
2. Is there any reasonable chance that this dosage/ approach will better control the disease, or is it merely a way into Pred dependency.

I am inclined to try this suggestion because a low dose regularly would be less Pred overall than what I take in bursts once every six weeks, and in any event if the flares increase in regularity I'll be on higher dose half the time. That would be when I would consider Remicade instead.

Comments on this approach from your experience, anyone please, will be appreciated. Note I am 58 so my lifetime accumulation of crap from the prednisone will be less than for a younger person.

Thanks anybody who replies>
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Crohn's Disease Forum » Treatment » Prednisone/Entocort » Overview of Corticosteroids
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