Thursday, February 15, 2018

Dr. Hyman, what are steroids and why do we use them?

Debunking Steroid Myths
Most people associate steroids with bodybuilding or injections, but steroids are also naturally occurring meaning that the body can make its own steroids. Steroids that are administered from outside the body, often in the clinical setting, are called “exogenous” steroids. 

The most commonly thought of steroid is “cortisone.” People will use the term “cortisone” interchangeably with steroid. 

So, what are steroids, really?
Steroids are hormones. Hormones are chemicals that signal cells to perform an action at the tissue level. In this case, steroids might signal nerve cells to calm pain signals and are also the most potent anti-inflammatory drug, meaning it will stop a cell from releasing other chemicals that promote inflammation. In our clinic, we use steroids to independently relieve pain by calming the nerve signals that carry pain signals and to suppress inflammation. 

We traditionally use steroids almost anywhere and everywhere—it has been a ubiquitous drug, either given by mouth or injected. Typically, we are using injectable steroids in our practice. Why? Because we have the ability to figure out the specific tissue that is the source of pain and thereby can target that tissue with the injected steroid. If you take steroids by mouth, it goes through the entire system and has a larger chance of affecting cells in your whole body, potentially causing a variety of side effects.

What are the potential side effects of injected and systemic steroids?
Some of the most common and usually temporary steroid side effects are insomnia, mood swings, flu-like symptoms, weight gain, increase in blood sugar, abnormal menses, and palpitations. A reduction in bone density is one longer-term adverse effect of exogenous steroids. Again, steroids are hormones and hormones can have both tissue level and systemic effects. For example, melatonin is a hormone that helps our body sleep and melatonin can be influenced by steroids, thereby creating the side effect of insomnia. Steroids can disrupt all other hormone pathways. While not always true, injected steroid may minimize those systemic side effects. 

And the truthfully, there are probably still some systemic effects of steroids because we have these little blood vessels nearby injured tissues that take up the injectable steroid. So there may be some systemic effects even when injected, potentially. 

Additionally, there is some evidence to suggest that injectable steroids can be damaging to tissue; steroid injections into the knee can degrade the cartilage more quickly and steroid injections may also increase the chance of rupture in some tendons. 

What can steroids help with?
It is important to note the risks of steroids and ensure appropriate use. When steroids are used in a targeted and appropriate manner, they can be a wonder drug; decreasing swelling, reducing pain, and restoring mobility. Typical uses for steroid include: swelling in a soft tissue, bursitis, adhesive capsulitis (frozen shoulder), and epidural injections into the spine. Steroid injections into these areas carry relatively low risk with great potential improvement for carefully selected patients. 


I’ve been prescribed Prednisone (oral steroids) in the past and it helped. Why not try that?
Again, there is a greater side effect profile with oral steroids because they are distributed throughout the body. The benefits of an oral steroid may also be more transient and may not be prescribed at a high enough dose to be effective. 

How often can I have a steroid injected?
Short answer: it depends on the body part. In weight-bearing joints—like the ankle, knee, and hip—we try to be stingy with steroid and maybe not use it at all. Steroid injections in these joints may last only a few weeks and there is evidence that steroid can increase the rate of cartilage loss in the knee. In contrast, epidural steroid injections into the spine may be given liberally as a tool to prevent surgery and promote an active recovery. Insurance only pays for surgery and steroids for most musculoskeletal and spine pain whereas other treatments may be a better option. Other therapies like prolotherapy, PRP (platelet rich plasma), stem cells, and viscosupplementation are not covered by insurance but may be the better option.  

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