Bright Sight

Oliver Backhouse, Consultant Eye Surgeon www.cataract.org.uk

Steroid (Prednisolone) treatment

Prednisolone is a steroid tablet. It is similar to one of your own naturally occurring hormones and has a powerful effect against inflammation. It is commonly used by people who have severe arthritis and asthma, but is also used in many other inflammations such as uveitis (inflammation in the eye).

The Uveitis Clinic is a special clinic that treats people with certain forms of uveitis. Sometimes only steroid eye drops are needed to control the inflammation but more severe uveitis needs steroid tablets. Some forms of uveitis affect vision rapidly, others much more slowly. If severe uveitis within the eye goes untreated it will cause permanent loss of vision. In such circumstances, your doctor may recommend that you use steroid tablets.

Steroids only suppress the inflammation and do not ‘cure’ it. Some types of uveitis only last for a short time (a few weeks or more) then disappear by themselves. However, even in this short time, they may cause considerable damage to vision. Some forms of uveitis get ‘switched on’ by unknown causes and, for some reason, the body can not ‘switch off’ the inflammation. In this way, uveitis can last for many years and, during this time, damage to vision often occurs. In this circumstance, Prednisolone may be prescribed to try and minimise this damage but, because the inflammation does not go away, Prednisolone needs to be taken for long periods of time.

Prednisolone tablets have many effects upon the body and it is important that you understand them. The effects vary between individuals and can depend on the dose and duration of treatment. If Prednisolone is prescribed for you, it is important that you carry the steroid card the pharmacist gives you at all times. Any doctor that you see will need to know that you are on steroids. It is very important that you take the exact dose prescribed and do not stop taking the treatment suddenly.

Prednisolone is often started at a high dose in order to ‘gain control’ of the inflammation. Once it has begun to take effect the dose will be reduced. Your eyes will be followed closely during this period to see what dose of Prednisolone is required. Some patients need to continue with a high dose in order to minimise damage to vision. This will lead to long-term side effects. Every attempt will be made to reduce the dose of Prednisolone, but sometimes it is necessary to combine treatment with other ‘steroid sparing’ drugs such as Azathioprine, so that the dose of Prednisolone can be reduced further. This is usually necessary only for severe forms of uveitis.

Some forms of uveitis are not isolated eye inflammations, but are part of more generalised inflammation affecting other parts of the body. It may therefore be necessary for such patients to see other specialists at some time. In such circumstances the best treatment, or combination of treatment, may be decided after discussion between specialists.\If Prednisolone is to be prescribed for your eye inflammation, you will need to know about potential problems associated with it. The most important of these are:

1. Psychological changes.

Some people, when starting prednisolone, usually at high doses, notice that their mood changes. This may be moodiness and depression or elation and a feeling of well-being. Sometimes sleep is disturbed. These effects usually reduce and disappear as the dose is reduced.

2. Stomach irritation.

Steroids can upset the stomach. It may take the form of nausea, feeling of fullness or mild indigestion. Occasionally there is more discomfort. Often ‘stomach protection’ medicine (Lansoprazole) is given when starting steroids. It is important to tell the doctor if you have ever had a stomach ulcer in the past. Some medicines, including aspirin and ibuprofen (which are contained in many headache medications) can cause stomach irritation. Do not use these together with Prednisolone except on the advice of your doctor.

3. Weight.

Weight gain is frequent and is partly due to increased fluid retention and increased appetite. You will be regularly weighed. Try and ensure your weight is kept under control from the start of treatment.

4. Diabetes.

Occasionally diabetes develops with people using steroids or those who are already diabetic find their diabetes difficult to control. Your urine will be checked regularly to check for this problem that affects only a few patients.

5. Blood pressure.

High blood pressure can develop in people using steroids. Sometimes this needs to be treated. Your blood pressure will be measured regularly in clinic.

6. Infection.

Prednisolone affects your body’s immune system and affects the way that your body fights infection. For those patients taking only a low dose, this is very unlikely to cause problems. For those needing higher doses, especially those also using other drugs to combat inflammation, there may be a problem with 3 infections in particular:

A) Chicken Pox:
If you have already had chicken pox you are not at risk. If you are not sure or have not been immunised you should avoid contact with anyone who has chicken pox or shingles. Should you come in contact with anyone with these conditions, get in touch with your GP and he / she may organise for a protective injection.

B) Measles:
If you have been immunised against measles (MMR vaccine) you are not at risk. If you are not sure or have not been immunised you should avoid contact with anyone who has measles. Should you come in contact with anyone with measles, get in touch with your GP and he / she may organise for a protective injection.

C) Tuberculosis:
If you come into contact with anyone who has TB, it is important that you contact your doctor who will arrange for you to have a chest x-ray and keep a check on any future developments. If you have previously had TB yourself, it is essential that you tell your doctor before you begin to use Prednisolone.

7. Osteoporosis.

Osteoporosis is a weakening of the bones. It is a common problem, especially in women after the menopause. It makes the bones more liable to break following a fall or, if osteoporosis is severe, bones can break without injury. Steroids, if taken for a long period of time at a sufficient dose, can cause osteoporosis and make osteoporosis worse if you already have it. Many drugs can increase bone density while on steroids but the success of reducing fracture rate is not clear.

Measures to try and reduce the risk of Osteoporosis:

  • Courses of Prednisolone will be kept as short as possible.
  • Doses of Prednisolone will be kept as low as possible. There is no ‘safe dose’ of Prednisolone but under 7.5mg a day has a low risk.
  • Calcichew D3 is often prescribed to help maintain bone structure. Foods rich in calcium are: dairy products, spinach, broccoli, oranges and prawns. A high salt intake should be avoided.
  • Regular exercise, especially involving weight-bearing bones such as the hips and backbone, is known to reduce the problem of osteoporosis and to make fractures less likely and it is encouraged especially while taking Prednisolone.
  • Reducing weight reduces stress on bones. It is important to try and keep your weight under control.
  • Try to stop smoking. Smoking makes osteoporosis worse.
  • Reduce alcohol intake. Alcohol may make osteoporosis worse.
  • Despite all the above measures, some patients may still develop significant osteoporosis, especially postmenopausal women. If you are after the menopause, Hormone replacement therapy (HRT) may be recommended and your general practitioner will explain the implications of treatment before it is started. Some women do not wish to use HRT, or take it for the maximum recommended period of 5-10 years. For these women and men who are found to be developing osteoporosis, alternative treatment with Alendronate may be started.

8. Adrenal glands.

You own ‘natural prednisolone’ is made by your adrenal glands above the kidneys. Long periods of Prednisolone use can reduce the amount your own adrenal glands can make of this essential hormone. You must never stop your steroids unless instructed by your doctor as your own adrenal glands will not be able to be suddenly ‘switched on’. Stopping steroids is undertaken gradually to allow your adrenal glands to recover.

9. Changes to skin, muscle and body shape.

Moderate or high prolonged steroid use changes the way fat is distributed in the body. Fat may accumulate on the hips, stomach and shoulders. Sometimes the face becomes puffy and the cheeks red. Sometimes more facial hair grows. Skin tends to be thinner than normal and blood vessels more fragile. There is therefore a greater tendency to bruise after a minor injury. Occasionally muscles become thinner and weaker. These effects are most often seen in patients who have taken Prednisolone for long periods of time.

10. Eye Problems:

a) Glaucoma.
Prednisolone can cause a painless pressure rise in the eye. If the pressure remains high for a long period of time it can cause damage to the vision. Under 5% get a significant pressure rise when using steroid eye drops and the risk with steroid tablets is even less. Pressure rises are usually successfully controlled with pressure lowering eye drops. It is important to realise that uveitis is also a common cause of raised pressure in the eye. If raised pressure does occur it is more likely to be due to the uveitis and not the treatment.

b) Cataract.
Prednisolone can cause a cataract (clouding of the lens in the eye). If bad, an operation to remove the cataract is possible but this needs special care in patients with uveitis (See Uveitis and Cataract patient information sheet). Cataract is common in patients using more than 5mg a day of Prednisolone for a period of years. It is important to realise that uveitis is also a common cause of cataract. If a cataract does develop it is just as likely to be due to the uveitis itself as the steroid treatment.

Every effort is made to minimise the side-effects of Prednisolone treatment. There is no drug useful for the treatment of uveitis that is entirely free of potential or actual side-effects. Every patient and every eye inflammation is different.

Disclaimer: Adapted from Manchester uveitis patient leaflet.