Doctors commonly prescribe glucocorticoids to help get arthritis symptoms in check. These powerful meds can reduce inflammation quickly to provide faster relief of such symptoms as pain and swelling, but people with arthritis might not necessarily be aware of how these drugs can affect their risk of getting sick from an infection.
We spoke with University of Pennsylvania rheumatologist Michael George, MD, to better understand the risks and benefits of corticosteroids, especially as it pertains to managing and reducing the risk of infection.
What Are Glucocorticosteroids?
Also called corticosteroids or steroids, these medications are commonly prescribed to people with inflammatory arthritis, such as rheumatoid arthritis, because they do two key things: They reduce inflammation and turn down the activity of the immune system.
Corticosteroids are similar in structure to cortisol, one of the hormones your body naturally produces.
Corticosteroids come in different forms, including oral pills, injections, inhalers (nasal sprays), solutions, and topical (lotions, gels, and creams). For treating rheumatoid arthritis, prednisone is the most commonly used corticosteroid. Other common forms include:
- Dexamethasone (Decadron)
- Methylprednisolone (Depo-Medrol, Medrol)
- Prednisolone
- Triamcinolone (Aristospan)
“Almost all cells in the body have a glucocorticoid receptor, so glucocorticoids have a wide range of effects on the body, including metabolism, blood sugar regulation, and the immune system,” says Dr. George, an instructor of medicine at the University of Pennsylvania.
That also means corticosteroids can have a wide range of side effects. The higher the dose of corticosteroids and the longer you take them, the greater your risk of side effects.
One such side effect is the risk of infections — everything from everyday infections like the common cold to infection after surgery (for example, joint replacement surgery), as well as pneumonia and shingles. At high doses, corticosteroids can be associated with less common infections such as tuberculosis and fungal pneumonia.
If you’re taking corticosteroids as a part of your arthritis treatment — or may need to take them in the future — it’s important to understand possible infection risks and how to avoid them. Here’s what you need to know.
Why Are Corticosteroids Recommended for My Treatment?
One major benefit of corticosteroids is that they work quickly, while many other medications can take weeks or even months to start controlling your symptoms.
“For this reason, glucocorticoids are often used early on in the treatment of rheumatoid arthritis to help control symptoms, acting as a bridge until other medications that have fewer side effects start controlling the disease,” says Dr. George.
Ideally, he says, corticosteroids are used for the shortest time at the lowest dose needed to control symptoms. That’s because although they work quickly, they can have undesirable side effects that can worsen the longer someone stays on them.
However, sometimes it can take time to find the best treatments for someone’s rheumatoid arthritis. And some people can remain on low doses of corticosteroids (for example, 5 mg of prednisone) for long periods of time.
Corticosteroids are also often used to help manage arthritis flares. “Some patients will have occasional flare ups of their rheumatoid arthritis that can be treated with a short burst of glucocorticoids for one to two weeks,” says Dr. George.
How Do Corticosteroids Affect Infection Risk?
Corticosteroids can raise your risk of infections because they have a wide range of effects on the immune system. The medication dosage has a big impact on the risk of infection. The infection risk is greatest at high doses (for example, 60 mg of prednisone), “but the risk of serious infection has been found to be approximately doubled even in people taking 10 to 20 mg of prednisone,” says Dr. George. The risk of infection with doses of corticosteroids below 10 mg is not clear, he notes.
The risk of infection can begin shortly after you start taking corticosteroids, but it goes up after you’ve been on treatment for several weeks and increases with time.
What Kind of Infections Are We Talking About?
Glucocorticoids increase the risk of both common and rare infections, says Dr. George. Infections that corticosteroids increase your risk of include:
- Pneumonia and other bacterial infections
- Shingles
- Common cold and other viral infections (although this has not been well studied)
- Surgical site infection (such as after a joint replacement)
- Tuberculosis, fungal pneumonia (at higher doses)
Corticosteroids also have a host of other potential side effects, aside from infection risk. Common side effects include weight gain and mood swings. Other side effects include:
- Muscle weakness
- Blurred vision
- Hair thinning and excessive hair growth
- Bruising
- Slow wound healing
- Acne
- Osteoporosis
- High blood pressure
- High blood sugar
- Stomach irritation or ulcers
- Glaucoma or cataracts
- Roundness of the face
Do Certain Kinds of Arthritis Patients Have a Higher Infection Risk than Others?
Anyone taking corticosteroids has an increased risk of these infections, but people with certain risk factors or health issues are more vulnerable. These include:
- Older age
- Diabetes
- Lung disease
How Does the Infection Risk of Corticosteroids Compare with DMARDs?
Corticosteroids reduce inflammation, but they are not as effective for protecting your joints and other body parts from permanent damage from having inflammatory arthritis, which is what DMARDs (disease modifying anti-rheumatic drugs) do. DMARDs come in two main categories: conventional DMARDs (such as methotrexate) and biologic DMARDs (such as anti-TNF drugs).
People with arthritis commonly assume that corticosteroids are safer than newer biologic therapies because corticosteroids have been around longer, says Dr. George, “while biologic therapies are more ‘new.’”
In fact, higher doses of glucocorticoids increase the risk of infection more than biologic therapies.
Long-term use of 10 to 20 mg per day of prednisone seems to increase the risk of infection more than TNF inhibitors or other biologic therapies, according to Dr. George. Conventional DMARDs like methotrexate have a smaller risk of infection than either glucocorticoids or biologics. The risk of infection with lower doses of glucocorticoids (less than 10 mg per day of prednisone) is not certain. Some studies suggest that these doses also increase the risk of infection about the same amount as biologic therapies, while other research has not shown this.
“Glucocorticoids are very commonly prescribed and the risks of infections with glucocorticoids may not always be discussed thoroughly,” says Dr. George. “On the other hand, when a biologic therapy is started, there is often a more detailed discussion about infection risk. Advertisements also have made patients very well aware of the possible side effects of these [biologic] treatments.”
If I’m Taking Corticosteroids, What Can I Do to Reduce My Infection Risk?
First of all, remember that infection risk is just that — risk. “Most patients taking taking glucocorticoids, especially at more modest doses around 10 mg, will not experience a major infection, and patients do not need to disrupt their lives to try to avoid infections,” says Dr. George.
The following hygiene tips can help you reduce your exposure to infection-causing germs:
- Wash your hands or use hand sanitizer throughout the day
- Avoid close contact with people who are coughing and sneezing
- Practice general good health habits (get enough sleep, exercise regularly, eat a nutritious diet)
- Get your annual flu vaccine
- Follow your doctor’s recommendations for getting other vaccines, such as pneumococcal, which can protect against some kinds of pneumonia, and those that protect against shingles
A Final Word from CreakyJoints
“Glucocorticoids can be very helpful in the treatment of disease and can make patients feel much better, but it is important to find other therapies to control the disease that will be safer for long-term use,” says Dr. George.
If you’re concerned about your infection risk while taking corticosteroids, make sure to bring this up with your doctor and ask questions.
“The key to any treatment decision is to understand the benefits of treatment, the risks of treatment, and the pros and cons of alternative treatments,” says Dr. George. You can ask your doctor to outline a few possible treatment approaches and ask about the risks of each. Doing this will help it easier to decide on a treatment now, and also make it easier to re-evaluate the plan down the road if you’re experiencing side effects or don’t think the treatment is working well enough to control symptoms or prevent disease progression.
Michael George, MD, is board certified in internal medicine and rheumatology.
