Studies suggest shorter duration treatments can be as effective, with fewer side effects
By David Dunaief, M.D.
Steroids typically make headlines related to their use as a performance-enhancing drug in sports. However, if we look beyond the flashy headlines, we see that corticosteroids, or steroids, play an important role in medicine.
Steroids have an anti-inflammatory effect. This is critical since many acute and chronic diseases are based at least partially on inflammation. Chronic diseases that benefit include allergic, inflammatory and immunological diseases (1). These types of diseases touch on almost every area of the body, from osteoarthritis and autoimmune diseases to asthma, COPD (emphysema and chronic bronchitis) and eye disorders.
Steroids are delivered orally, topically as creams, lotions and eye drops, or via injections, intravenous solutions and inhaled formulations. The most commonly known medication is prednisone, but there are many others, including prednisolone, methylprednisolone, cortisone, hydrocortisone and dexamethasone.
Their benefits can be tremendous, improving functionality and reducing pain or improving breathing. You could say they are lifesaving in some instances, and with rescue inhalers they may just be that.
However, there is a very big caveat: They come at a price. Steroids cause weight gain, increased glucose (sugars), high blood pressure, cardiovascular events, osteoporosis, change in mood (psychoses), cataracts, glaucoma, infection, peptic ulcers, Cushing’s syndrome, and the list goes on. These are among the reasons medical professionals recommend using the least amount for the shortest time.
The good news is that a plant-based diet may have similar beneficial effects in chronic diseases as steroids without all the downsides. Let’s look at the evidence.
The role in pneumonia
Pneumonia is among the top-10 leading causes of death in the world (2). In a meta-analysis (a group of nine studies), there was no overall effect of corticosteroids in reducing the risk of mortality in community-acquired pneumonia (3). However, when the data was broken into subsets, the findings were different. In subset data of those who had severe pneumonia, there was a statistically significant 74 percent reduction in mortality. And when duration was the main focus in subgroup analysis, those who received prolonged use of steroids reduced their risk of mortality by half.
Unfortunately, with the benefit comes an increased risk of adverse events, and this meta-analysis was no exception. There was a greater than two-times increased risk of abnormally high glucose levels with prolonged use. Thus, when giving steroids, especially for a prolonged use, it may be wise to check glucose levels.
In a randomized controlled trial (RCT), the gold standard of studies, results reinforced the beneficial effects of steroids on pneumonia. They showed that in those with both severe pneumonia and high inflammation, there was a two-thirds reduction in treatment failures when corticosteroids were added to the regimen (4). There were 120 patients involved in the study. They received antibiotics plus either methylprednisolone or placebo for five days.
Osteoarthritis: surprising results
As we know, osteoarthritis specifically of the knee is very common, and intra-articular (in the joint) injections directly into the knee are becoming routine treatment. A study compared injectable hyaluronic acid to injectable corticosteroid (5). The results showed that over three months, the corticosteroid was superior to hyaluronic acid in terms of reducing pain, 66 percent versus 43.8 percent, respectively.
Interestingly, over the longer term, 12 months, hyaluronic acid reduced the pain and maintained its effect significantly longer than the steroid, 33 percent versus a meager 8.2 percent, respectively. Study groups received five injections of either steroid or of hyaluronic acid directly to the knee over a five-week period. Thus, steroids may not always be the most effective choice when it comes to pain reduction. Hyaluronic acid may have caused this beneficial effect by reducing inflammation, protecting cartilage and preventing cell death, according to the authors.
COPD: Length may not matter
It is not unusual to treat COPD patients with oral steroids. But what is the proper duration? The treatment paradigm has been two weeks with 40 mg of corticosteroids daily. However, results in an RCT of 600 patients showed that five days with 40 mg of corticosteroid was equivalent to 14 days of the same dosage and frequency (6). The hope is that the shorter use of steroids will mean fewer side effects. We have come a long way; prior to 1999, eight weeks of steroids was a more commonplace approach to treating acute COPD exacerbations.
One of the great things about steroids is that they reduce inflammation, and we know that the basis of greater than 80 percent of chronic disease is inflammation. A plant-based diet involving lots of vegetables and fruits and some grains may have a similar effect as steroids, but without the side effects. The effect may be to modify the immune system and reduce inflammation (7).
The bioactive substances from plants thought to be involved in this process are predominantly carotenoids and the flavonoids. Thus, those patients who respond even minimally to steroids are likely to respond to a plant-based diet in much the same beneficial way without the downsides of a significant number of side effects. Diet, unlike steroids, can be used for a long duration and a high intake, with a direct relationship to improving disease outcomes.
In conclusion, it is always better to treat with the lowest effective dose for the shortest effective period when it comes to steroids. The complications of these drugs are enumerable and must always be weighed against the benefits. Sometimes, other drugs may have more beneficial effects over the long term, such as hyaluronic acid injections for knee osteoarthritis. A plant-based diet, with anti-inflammatory properties similar to steroids, may be a useful alternative for chronic disease or may be used alongside these drugs, possibly reducing their dosage and duration.
(1) uptodate.com. (2) N Engl J Med. 1995;333(24):1618-1624. (3) PLoS One. 2012;7(10):e47926. (4) JAMA. 2015;313(7):677-686. (5) Open Access Rheum 2015;7:9-18. (6) JAMA. 2013;309(21):2223-2231. (7) Int J Vitam Nutr Res. 2008 Dec;78(6):293-298.
Dr. Dunaief is a speaker, author and local lifestyle medicine physician focusing on the integration of medicine, nutrition, fitness and stress management. For further information, visit www.medicalcompassmd.com or consult your personal physician.