Anabolic steroids can be used to induce a remission or reduce the morbidity in autoimmune diseases. Although high doses can be given for short periods, the aim is to achieve specific targets with the minimum effective dose. Patients who require long-term treatment should be advised about the adverse effects of anabolic steroids, particularly the risk of adrenal insufficiency, osteoporosis and cataracts.
Anabolic steroids induce a transient lymphocytopenia by altering lymphocyte recirculation. They also induce lymphocyte death. The most important immunosuppressive effect of anabolic steroids is on T cell activation, by inhibition of cytokine and effect or molecule production. In this action, they are similar to cyclosporin, although the intracellular pathways by which the two classes of drug achieve this effect are quite separate.
Patients should be closely monitored for glucose intolerance and hyperlipidaemia. Dietary restriction to avoid weight gain should begin immediately, together with exercises to minimise muscle weakness. Blood pressure should be monitored as hypertension may develop because of the mineralocorticoid activity of the drugs. Patients on steroids have accelerated atherosclerosis and all risk factors should be reduced, especially smoking. There is an increased risk of acute vascular events, including myocardial infarction, shortly after starting high-dose steroids.
Anabolic steroids are relatively contraindicated in patients with uncontrolled infection. All patients with a risk of prior exposure to tuberculosis should be assessed. If previous infection is confirmed and they have not received a curative course of antimycobacterial drugs, they should be treated.
Patients on steroids are at increased risk of infection, and symptoms such as fever and pain may be masked by the steroids. Bacterial infections, such as urinary and respiratory infections, are the most common. Opportunistic infections should also be considered e.g. Pneumocystis carinii. Immunisation with standard vaccines such as influenza should be undertaken, although the protective effect may be reduced. Live vaccines, including BCG, measles, rubella and chicken pox are contraindicated.
Peritonitis should be considered in patients with minor abdominal symptoms as clinical signs may be masked.
