15. steroids.pdf

An American Perspective reprinted from: June 03
Title: Use of Steroids in Persons With ITP – A Boon and a Bane
Authors: James N. George, M.D., Oklahoma City, George R. Buchanan, M.D., Dallas
A class of drugs called corticosteroids was developed in 1950 and has been used to treat patientswith ITP ever since.
So what are these agents? They are similar to natural corticosteroid hormones. Hormones arechemicals that are made by the body, circulating in the blood, and having an effect elsewhere in thebody. All corticosteroids have a similar chemical structure. They include estrogens (female hormones)and androgens (male hormones). However, the form of cortico-steroids most widely used in ITPare glucocorticoids, which are important in the body’s metabolism, salt and water balance, andresponse to stress. During the past four decades physicians have found a use for glucocorticoidpreparations (or steroids as we shall refer to them subsequently) in a variety of conditions, includingkidney disease, cancer, skin problems, and autoimmune disorders.
So how do steroids benefit persons with ITP? Their major effect is a rise in platelet count (oftenwithin a few days) secondary to blockage or “paralysis” of the spleen, the major site of plateletdestruction in ITP. After a few weeks of treatment steroids also decrease the amount of anti-plateletantibody made by the body’s immune system. Steroids may also reduce bleeding even withoutraising the platelet count by means of strengthening or stabilizing the blood vessels.
The good news is that steroids often help patients with ITP. But, as many ITP patients know, thebad news is the many side effects of steroid therapy. Virtually all ITP patients taking steroids sufferfrom one or more adverse reactions. Most patients taking steroids have changes in their mood.
This can include irritability, anxiety, and insomnia. Children often experience hyperactivity. Manypatients also have vague aches and pains. Gastrointestinal side effects are also frequent, rangingfrom mild stomach irritation to bleeding ulcers (which fortunately are rare and perhaps can beprevented by use of antacid medication).
Even in the short term steroids may reduce the body’s immunity, leading to thrush and a small riskof serious chickenpox and other viral infections. Steroids also lead to an increase in appetite,causing puffiness, weight gain and potentially an increase in blood pressure (due to the body'sretention of salt and water). Unfortunately, some patients with ITP remain on steroids for prolongedperiods of time (many weeks or months) and are therefore susceptible to delayed complicationssuch as bone injury (osteoporosis or thinning of the bones and avascular necrosis, a seriouscomplication involving damage to the hip bone), cataracts impairing vision, and diabetes mellitus(sugar diabetes). Also, children on long-term steroids may exhibit impaired growth. Many patientswith ITP have learned that the side effects of steroids seem to outweigh the apparent benefits ofraising the platelet count and reducing bleeding.
There are several kinds of steroids. The oral agents most commonly used in children and adultswith ITP are prednisone, prednisolone, or methylprednisolone. Actually, these three medicinesdiffer slightly but they are used by doctors interchangeably. The usual starting dose of prednisonefor adults is usually between 40 and 100 mg daily. Sometimes when bleeding is severemethylprednisolone is given by vein. After a period of time the steroid dose is usually reduced andsometimes given on alternate days. The natural hormonal form of glucocorticoid, called cortisol, ismade by the adrenal glands, small glands situated above each kidney. When a person takes prednisonedaily, the adrenal gland is fooled into not making the natural hormone. This can be potentially dangerous when steroid medication is abruptly discontinued, because recovery of adrenal glandfunction to produce the body’s own cortisol may require weeks to months. If a patient has been onsteroid medication for longer than a few weeks, the dose must be decreased gradually, especiallywhen the dose has dropped to 7.5 mg per day, to allow adrenal gland production of cortisol torecover. Cortisol production may be critical for survival at times of severe illness or injury. Thereforeif a severe illness or injury occurs in a patient on a low dose of prednisone (such as 5 to 10 mg perday) or in a patient who has recently stopped taking steroid medication, high doses of steroid,comparable to the body's stress response are essential. Suppression of the adrenal gland andperhaps other side effects are somewhat less when prednisone is given as a single dose in themorning once every other day.
The other steroid sometimes used in patients with chronic ITP is dexamethasone, or decadron.
The usual adult dose is 40 mg daily for 4 consecutive days, repeated once monthly. When steroidmedications are given for brief times, such as 4 days, it is not necessary to gradually decrease thedose. One theoretical benefit of dexamethasone is that it stays in the body longer than prednisone.
A few years ago this treatment was widely used, but with more experience it has been learned thatit is not generally a successful treatment and it is now used much less frequently.
So what is the bottom line about use of steroids in ITP? For many ITP patients, steroids are quitebeneficial, if used properly. A patient should take a steroid medication with the aim of reducingbleeding and being able to live a better life. The objective should not be normalizing the plateletcount. Steroids should, ideally, be used sparingly and only in the short term – for a few weeks atmost. Their continued use at any dose or schedule is often not appropriate for ITP. Unfortunately,many physicians (hematologists as well as general practitioners) who are not experts in ITP fail touse steroids properly. They often continue to prescribe large doses (trying to make the plateletcount higher), even when reducing or discontinuing the medication would be more appropriate. Ifsteroids are not effective, they should be discontinued so that other treatment options can beconsidered, including “watchful waiting” (since many patients with ITP aren’t that troubled by theirdisease and need no drug therapy whatsoever), intravenous immunoglobulin, anti-D immunoglobulin(available in the United States and now recently in the U.K.), splenectomy, or newer experimentalagents.
In conclusion, steroids can be a “friend” of many bleeding ITP patients by reducing hemorrhage.
However, this friendship is nearly always temporary. It is important not to remain on high doses ofprednisone for too long a time, for too much of a good thing can be bad, just like beer, ice cream,television, and many things in our lives! N.B. Steroid users should carry a blue card issued by the hospital that is updated each time the dosage is
changed.

Source: http://www.itpsupport.org.uk/american/15.%20Steroids.pdf