Although hormones can reduce the clinical symptoms of patients, their adverse reactions make patients resist the use of drugs, and even reduce or stop the drugs prescribed by the doctor on their own. In recent years, the concept of standard-based treatment has been gradually applied to the treatment of SLE, with the specific goals of inducing remission, maintaining disease stability, and preventing relapse. Glucocorticoids are one of the more commonly used drugs in SLE induction of remission.
Is it appropriate to emphasize "zero medication" for hormones now?
Except for some lupus patients with mild and low disease activity, most of the rest of the patients still need to use hormones in the initial initial induction remission treatment stage, especially those with important organ damage, such as lupus nephritis, neuropsychiatric lupus, etc. Hormones can be reduced and stopped only after a stable period of symptom relief is reached.
Why pursue "zero medication" for hormones?
Glucocorticoids can significantly reduce mortality in patients with acute lupus, but corticosteroids can only control symptoms and cannot alleviate the root cause. Long-term use of glucocorticoids is prone to many adverse reactions, such as osteoporosis, metabolic disorders, and irreversible organ damage. Therefore, the guidelines of the Federation for the Prevention and Treatment of Rheumatology recommend that the corticosteroid dose should be reduced to prednisone ≤ 7.5 mg or equivalent in the medium and long term treatment of SLE, and the corticosteroid should be gradually discontinued if possible.
How to achieve "zero medication" of hormones for lupus treatment?
The Rheumatology Association guidelines recommend two ways to use glucocorticoids:
(1) Intravenous pulse use of different doses of methylprednisolone (therapeutic dose is related to disease severity and weight), high-dose intravenous infusion of methylprednisolone (usually 250 - 1000mg/day for 3 consecutive days), commonly used to exclude patients with acute and/or severe organ function involvement after infection, this medication mode takes advantage of the non-genomic effects of glucocorticoids, helps to reduce the initial oral dose of corticosteroids and achieve rapid tapering.
(2) The guidelines have repeatedly emphasized that for patients with organ damage, immunosuppressants should be added for treatment in a timely manner, with the aim of inducing disease remission and reducing the amount of hormones. Early combination of immunosuppressants can be beneficial for corticosteroid taper and eventual discontinuation.
Highlights of the updated guidelines for the use of glucocorticoids in SLE guidelines
1. Determine the dose and route of glucocorticoids according to the type and severity of the affected organs.
2. Intravenous pulse methylprednisolone (250 - 1000 mg/day, combined with 1 - 3 days) therapy, with rapid onset of action, can significantly reduce the starting dose of oral glucocorticoids.
3. In the maintenance phase of the chronic phase, glucocorticoids should be reduced to less than 7.5mg (prednisone or equivalent glucocorticoids) per day and discontinued as soon as possible.
4. Appropriate and timely immunosuppressant therapy can help reduce and stop glucocorticoids.
Keep an eye out for these points when using hormones!
Dosage Essentials:
1. The best time to take oral hormones is 7-8 a.m., because the morning is the peak time for the body to secrete glucocorticoids, and taking the drug at this time can reduce the inhibitory effect of hormones on the function of the hypothalamic-pituitary-adrenal (HPA) axis.
2. After taking hormones, it is recommended to rinse your mouth with water or weak alkaline water, which can avoid drug residues and prevent oral flora disorders.
3. After the use of hormones, the body's metabolism accelerates, and there will be an increase in appetite. Patients should not overeat due to hunger and need to control their diet reasonably.
Adverse reactions:
1. Due to the risk of osteoporosis with corticosteroid use, calcium supplementation and regular or active vitamin D are recommended at the same time as corticosteroid use for patients who are expected to use corticosteroids for more than 3 months, regardless of the dose of corticosteroid. If there are ≥2 risk factors for fracture, additional bisphosphonates are required.
2. Short-term injections of glucocorticoids usually have little effect on menstruation, but long-term injections of corticosteroids may cause shortened menstrual cycles, prolonged menstrual periods, irregular periods, and excessive blood volume.
3. There are interactions between hormones and other drugs. Drugs such as carbamazepine, phenytoin, or rifampicin may reduce the effects of systemic hormones. Conversely, oral contraceptives or ritonavir can raise blood levels of the hormone. When used in combination with potassium-wasting diuretics (e.g., thiazides or furozodes), excessive potassium loss is likely to occur. When combined with NSAIDs, there is also an increased risk of gastrointestinal bleeding and ulcers.
Pregnancy, pregnancy, lactation:
1. The US FDA divides the risk of medication during pregnancy to the fetus into five levels: A, B, C, D, and X. Prednisone and methylprednisolone are classified as class B (adverse effects were not identified in the control group of women in the first trimester), and they have little effect on the fetus, mainly due to fetal development and intrafetal infection. Dexamethasone and betamethasone have significant effects on the fetus and are generally not used unless they are used to promote lung maturation in the premature fetus.
2. According to the short-term and long-term effects of drug application in lactation, it is divided into L1 - L5 grades. Prednisone, prednisolone, and methylprednisolone are all rated L2 (safer) during lactation. Dexamethasone has a risk rating of L3 (moderate safety) during lactation and is not recommended for long-term use due to its high pituitary-adrenal inhibitory effect.
3. The recommended maintenance dose of hormones used during pregnancy and pregnancy should not exceed the equivalent dose of prednisone 15mg per day. If the dose of prednisone equivalent is more than 20 mg per day (i.e. more than 4 tablets) during breastfeeding, it is recommended to take the drug 4 hours before breastfeeding.
Precautions for stopping hormone reduction:
1. Unauthorized reduction, rapid reduction or abrupt cessation of hormones may cause adrenal insufficiency symptoms or lead to recurrence or aggravation of the primary disease.
2. There is no fixed standard for hormone reduction, and it needs to be evaluated by comprehensively considering factors such as disease type, disease severity, hormone dose, duration of use, and adverse drug reactions. Indications for dose reduction and discontinuation usually include controlled disease; Failure to respond to hormonal therapy; Serious adverse reactions; Uncontrollable infections (e.g., chickenpox, fungal infections) should be decided by a specialist.
Hormones should be avoided in the following conditions: allergy to hormones, history of severe psychiatric illness, epilepsy, active peptic ulcer, recent gastrointestinal anastomosis, fractures, trauma repair, herpes simplex keratitis, conjunctivitis and ulcerative keratitis, corneal ulcers, severe hypertension, severe diabetes, uncontrolled infections (eg, chickenpox, fungal infections), active tuberculosis, more severe osteoporosis, early pregnancy and puerperium, psoriasis vulgaris, etc. People who are allergic to one hormone may also have allergies to other hormones, so they should be fully informed of their allergy history before seeing a doctor.
Patients ask why some "ancestral recipes" relieve symptoms.
People with lupus should never blindly believe ancestral recipes that claim to cure lupus, and some of them may be effective because they contain a lot of hormones that can quickly relieve symptoms. So how do we tell?
(1) According to symptoms and signs: long-term use of this ancestral secret recipe will cause centripetal obesity, polybody hair, skin thinning, increased fragility, pigmentation, acne, purple striae, petechiae, ecchymosis, facial congestion and telangiectasia.
(2) According to the performance after stopping the drug: Sudden discontinuation of this ancestral secret recipe may cause nausea, vomiting, dizziness, orthostatic hypotension, fatigue, weight loss, fever of no obvious cause (antibiotic treatment is ineffective), unexplained apathy or depression, etc. Hormones are a double-edged sword, and rational use is the best. "Zero hormone" also don't forget to have regular follow-up visits.