All my misfortune comes from the wrong friends... - Is this about cortisone?
Cortisone in anti-inflammatory therapy
The introduction of cortisone into the treatment of inflammatory diseases in the 1940s marked the beginning of the modern era in rheumatology. Cortisone preparations proved to be highly effective in a variety of inflammatory immune diseases in other areas of medicine and are still part of the standard repertoire of inflammation treatment today. Since then, numerous other anti-inflammatory drugs (immunosuppressants) have been introduced into the treatment of immune diseases, but cortisone preparations continue to occupy a special position due to their rapid onset of action and broad efficacy. To date, there is no other immunosuppressant that can interrupt a highly acute rheumatic inflammation as quickly and comprehensively as prednisolone, for example, today's leading cortisone preparation.
How did cortisone get the reputation of being a false friend? This reputation can be explained by its history. The first immunosuppressants used in rheumatology were only moderately effective and had to be combined with cortisone in the majority of cases. They were also moderately or poorly tolerated, and when they were discontinued, treatment had to be continued with higher doses of cortisone. As a result, patients were exposed to high cumulative doses over a long period of time and suffered a high number of cortisone side effects.
Effect of immunosuppressants on the need for cortisone
Fortunately, this changed at the end of the 1980s, when the introduction of a steadily increasing number of modern immunosuppressants led to a continuous reduction in long-term cortisone requirements. In the early phase of anti-rheumatic therapy, a long-term prednisolone dose of 7.5 mg was still considered acceptable, but from today's perspective, such therapy is inadequate. In addition to the reversible side effects such as weight gain, muscle loss, increased blood sugar and blood pressure and weakened immunity to infectious agents, there are also long-term side effects that cannot be reversed or can only be reversed to a limited extent, such as reduced bone stability/osteoporosis, clouding of the lens of the eye/cataracts, damage to blood vessels/arteriosclerosis and skin.
With the introduction of modern immunosuppressants, the rule was that concomitant prednisolone therapy should be limited to a maximum of 5 mg. Since the early 2000s, the introduction of biologics and, more recently, inhibitors of certain enzymes in immune cells has allowed this rule to be revised downwards once again. The current joint recommendations of the European rheumatology societies for the treatment of rheumatoid arthritis state "The short-term administration of cortisone preparations should be considered when starting or changing immunosuppressants, ... but they should be reduced and discontinued as soon as clinically possible (target: after a maximum of 3 months)". This recommendation should not be understood as a long-term goal, but reflects today's reality: the spectrum of immunosuppressants has become so broad that, depending on the diagnosis, long-term concomitant therapy with cortisone can be dispensed with in a large proportion of rheumatic inflammatory diseases.
Current use of cortisone
So will cortisone be dispensable sooner or later? Probably not in the foreseeable future. Unlike in long-term therapy, it will continue to be used in acute situations and will maintain its place. Acute application is carried out in cortisone bursts with a medium or high initial dose and a dose reduction over days to a few weeks, depending on the disease situation. The rapid onset of action of this form of therapy and the broad effect on many sub-components of the inflammation are utilized. The side effects such as an increase in blood sugar and blood pressure, restlessness, sleep disorders and changes in mood quickly subside as the dose is reduced.
quickly subside when the dose is reduced or can be counteracted with concomitant therapy. The often irreversible side effects of long-term cortisone therapy can be largely avoided.
Cortisone shock therapies are used in two situations in particular:
- at the start of therapy to bridge the time until the immunosuppressant takes effect - this can take several weeks depending on the medication used. With cortisone, a rapid improvement in symptoms is achieved, and effective therapy starting early also paves the way for a favorable further course of the disease,
- for initial therapy in organ- or life-threatening situations, particularly in the case of inflammatory connective tissue diseases/collagenoses or inflammatory blood vessel diseases/vasculitides.
Diagnostics under cortisone therapy
In general practice, cortisone may be used even before a detailed rheumatological diagnosis has been made in order to bridge the waiting time until the patient is seen by a rheumatologist. If we are informed of this, we try to arrange an appointment in one of our consultation hours as quickly as possible. The "Hamburg rheumatology form" is used for this purpose, in which the referring doctor forwards information on the urgency of the situation. In particular, if there is no confirmed rheumatological diagnosis, the cortisone dose must be reduced to a minimum before the first appointment. Medium/high doses of cortisone obscure the signs of the disease and also many of the diagnostic findings such as laboratory values, sonography and magnetic resonance imaging (MRI) results.
- To avoid wasting time in acute situations, the prednisolone dose should therefore be reduced to 5 mg or less for at least 3-5 days before presentation at the rheumatology consultation, and this time can be bridged with a painkiller if necessary.
- Cortisone shots shortly before the appointment also have this effect; the interval between the cortisone shot and the appointment should then be at least 2-3 weeks.
Cortisone - a false friend?
As previously reported, cortisone therapy in rheumatology has undergone a remarkable development. Whereas in the early days of anti-inflammatory therapy the desired effects often had to be bought at the price of serious undesirable effects, in inflammatory rheumatoid arthritis it has been possible to continuously reduce the amount of cortisone and its undesirable side effects. It is foreseeable that this development will also occur in the much rarer inflammatory connective tissue and vascular diseases, and a start has already been made.
In contrast to long-term treatment, cortisone used as a shock therapy remains an important component of acute therapy. The side effects of a short high-dose application are usually manageable and the benefits far outweigh the side effects.
It is time to rid cortisone of its dubious reputation. Used according to today's rules, it will remain an important aid in inflammatory medicine for the foreseeable future. However, as we have seen, it should be used with caution - we are familiar with its somewhat unforgiving nature from the past.
