Corticosteroid Risk and Natural Anti-inflammatories

Paul L. Reller L.Ac. / Last Updated: August 03, 2017

Corticosteroid therapy, a treatment to control the inflammatory processes to ease joint pain, decrease asthmatic bronchiole or tracheal swelling, decrease skin inflammation, or to decrease undesirable immune response in various autoimmune disorders, has long been considered an effective but potentially harmful means to decrease symptoms that are threatening to the patient. The high risk of serious side effects and long term damage to the hormonal, or endocrine system, has prompted most authors of medical texts to recommend that other therapies be tried before resorting to this type of therapy. Since corticosteroids are in a family of neurohormonal molecules called glucocorticoids, the first known adverse effects since introduction of the drugs in the late 1950s concerned the metabolic regulation of blood sugars (gluco-). Excess or chronic use of corticosteroids can also negatively affect the entire metabolic system as well. The array of serious adverse effects of synthetic corticosteroid use is broad though, commonly affecting the central nervous system due to the large concentrated number of glucocorticoid receptors in the brain, and disrupting vital immune, growth, tissue maintenance, and regulating effects in the body. Unfortunately, since the medical field has increasingly moved away from simpler conservative therapies to a greater dependence on new pharmaceutical approaches, and the pharmaceutical industry has not generated effective medications to treat inflammatory disorders, the use of corticosteroids has become routine rather than the treatment of last resort. As the overuse of synthetic corticosteroids has increased, a large amount of evidence of adverse effects and harm is harder and harder to ignore. A wealth of scientific study now confirms the potential for herbal and nutrient medicine to help with inflammatory dysfunction, though, as well as specific acupuncture and electroacupuncture stimulation, presenting an adjunct treatment protocol to reduce the use and dosage of corticosteroids. This information is available at the end of this article with links to studies. While we often need to resort to stronger medications with risks of, or commonly caused, adverse health effects, euphemistically still called "side effects", the intelligent patient will understand that to first try safe and gentle conservative therapies is sensible. Reversing the underlying health problems that lead to dependence on corticosteroids, or preventing diseases that require this care, often takes considerable time and effort, but is worth the trouble in the long term.

The widespread overuse of corticosteroid medication is causing many common health problems and could be easily reduced by a greater reliance on conservative care and Complementary and Integrative Medicine (CIM). Physiotherapy and acupuncture reduce the need for strong anti-inflammatory corticosteroids, and herbal medicine and acupuncture are very effective to reduce asthmatic symptoms and overdependence on corticosteroid inhalers. In addition, research is showing that simple oral and topical herbal medicines may significantly reduce the need for corticosteroid medication for infants and children. Complementary and Integrative Medicine (CIM/TCM) can also help normalize the natural cortisol balance in the body, reducing the need for synthetic corticosteroids by encouraging natural corticosteroid responses. Randomized controlled human clinical trials in 2013 and 2014 found that corticosteroid injections provided no benefit over placebo injections for chronic lateral epicondylalgia (elbow pain called Tennis Elbow), and low back or lumbar pain, often with pain radiating down the buttocks or leg (commonly called "sciatica"), and greater use of physiotherapies are now recommended for these musculoskeletal conditions, especially with increased warnings of harm from standard pain medications and NSAIDS as well, and recent large human clinical studies that have shown that acetaminophen provides very limited benefit for many types of pain. Use of such a harsh and potentially harmful medication as the corticosteroid injection for its placebo effects is now routine in standard medicine, but should be reconsidered (see study links below in Additional Information). The medical industry responded to numerous large studies showing little or no benefit from corticosteroid injections by more than doubling the prescription, and this should be alarming. Complementary and Integrative Medicine, such as Traditional Chinese Medicine (CIM/TCM) presents a solution to this problem, with an array of safe and effective therapies that are combined to form a more effective, and individualized, treatment protocol. Treatment protocols in CIM/TCM may be mainly palliative or may actually treat to restore healthy function and regrowth of healthy tissue, and more of this latter type of protocol should be encouraged. The combination of acupuncture needle stimulation, trigger point needling, deep soft tissue physiotherapy, and herbal and nutrient medicine can reverse the underlying health problems causing symptoms that the corticosteroid medications relieve. A more comprehensive package of care is usually needed to actually reverse these health problems and restore function and help the body to replace unhealthy tissue with new healthy growth. This requires more work, but the end result and benefits are worth the trouble.

The patient should consider and discuss potential side effects with the prescribing doctor when considering corticosteroid treatment and considering possible alternatives that are less potentially harmful. The National Institute of Health (NIH) gives these side effects as common for patients taking higher doses, and potential for all patients: stomach irritation, muscle weakness, increased blood pressure, diabetes (blood sugar spikes, diabetic retinopathy, fatty liver), fluid retention and weight gain, easy bruising, delayed wound healing or tissue repair, glaucoma, decreased calcium absorption and osteoporosis, and decrease in the body's natural production of corticosteroid hormones, lowering natural immune protections. In addition corticosteroids, even applied topically, have consistently shown to cause birth defects in laboratory animals. Corticosteroids may also lower your resistance to infections and make infections hard to treat, often resulting in prolonged and severe flare-ups of herpes outbreaks and systemic candidiasis. After prolonged use there is usually a prolonged time of adjustment, lasting up to a year, with side effects of muscle and joint pain, reappearance of disease symptoms, shortness of breath, tiredness or weakness, headaches, nausea, dizziness, fainting, abdominal pain, low fever and loss of appetite possible. While not all of these symptoms occur in every patient with prolonged use, the percentage of patients affected is high. Guidelines indicate that any use of moderate to high dosage of prednisone needs a protocol of gradual withdrawal rather than abrupt stopping of medication, even for courses of as few as 7 days. Often, the sudden withdrawal, and subsequent inhibition of the natural corticosteroid metabolism, is the cause of persistent symptoms and negative health consequences. Patients may consider integrating Complementary Medicine to stimulate a return of a balanced corticosteroid, or cortisol, homeostasis, with a healthy coordinated hypothalamic and adrenal function, and proper diurnal cortisol levels.

The National Health Service of the United Kingdom (UK) lists a number of common side effects noted in patients taking oral corticosteroids for less than 3 months. These include mood changes, rapid mood swings, acne, increased appetite and weight gain. With oral corticosteroid use for more than 3 months, the British Health Service warns of common side effects of further weight gain, thinning skin, easy bruising, muscle weakness, fatty deposition, especially in the face (moon face), osteoporosis and osteopenia, onset of diabetes, high blood pressure, glaucoma, cataracts, delayed wound healing, reduced growth in children and young adults, and increased risk of infection. The warnings include the fact that about 1 in 20 patients with chronic oral corticosteroid use experience changes in their mental state, which may include depression, anxiety, mania, confused feelings, frightening thoughts, suicidal thoughts, and hallucinations, as well as periods of cognitive difficulty. Since these symptoms onset slowly they are often not associated with the corticosteroid use, and the widespread practice of 'defensive medicine', or the failure to counsel patients on adverse effects of treatment due to a fear of malpractice lawsuit, has limited the necessary advice to patients concerning these well documented adverse effects. The National Health Service also warns that chronic corticosteroid use may increase risk of shingles (herpes zoster) and measles. Other warnings include (documented below in additional information) contraindications with the blood thinner warfarin, or coumadin, with oral corticosteroids potentially altering the effective circulating levels of these drugs, creating a dangerous situation. You would think that with the U.S. and British health services noting all of these adverse health effects that the use of corticosteroid medications would have been decreased, but it has not. Ignoring of documented risk and failure to discuss these risks adequately with patients is malpractice.

In addition, numerous studies have demonstrated that glucocorticoid inhalers commonly used to control asthmatic symptoms have a negative long-term impact on growth hormones. In 2012, the prestigious New England Journal of Medicine published a study of 943 children, ages 5 to 13, that were randomly assigned to take daily doses of a steroid inhaler or a placebo for 4 to 6 years, in addition to a bronchodilator, Albuterol. By the age of 25, those taking the glucocorticoid budenoside were on average a half inch shorter than those taking the placebo, and the higher dosage of glucocorticoid resulted in increased growth inhibition. The lead author of the study, Dr. H. William Kelly, Professor Emeritus of Pediatrics at the University of New Mexico School of Medicine, stated: "There are lots of studies that show the inhalant corticosteroids produce a decrease in growth in prepubertal children. But we have the first long-term prospective study that shows that you don't outgrow it." (NY Times Science Sept. 4, 2012 - Use of Inhalers May Affect Growth). With such a confirmed effect on growth hormones, it is not hard to surmise the overall negative effect on the endocrine system. By utilizing Complementary and Integrative Medicine, these common corticosteroid drugs may be reduced or eliminated, protecting the future endocrine health.

FDA and NIH guidelines for a higher dosage oral corticosteroid medication, such as prednisone, are routinely ignored in standard medicine today. In addition, scientific evaluation of incidence of harmful effects from synthetic corticosteroid use rely completely on case studies published, not RCTs, and the industry has succeeded in discouraging any large reliable studies of harmful effects, other than the studies used originally to obtain FDA approval. Nevertheless, these original studies showed such a high rate of side effects and harmful effects from withdrawal and chronic use that a long list of official warnings and guidelines do exist. Unfortunately, these are typically ignored. Reasoning for this prescribing behavior typically cites the lack of other viable therapies for acute threatening episodes of allergic or asthmatic states, or for more severe chronic disorders, such as autoimmune disorders, some cancers, and chronic inflammatory diseases. In the past, prednisone and other synthetic corticosteroid medication was reserved for more severe health problems, where the benefits, or need, exceeded the risk, or harm. Over time, these medications became gradually overprescribed, routine use implied that there was now less of a need for caution, and today, the patient is often the person that reads the prescribing guidelines and questions the use of the drugs. In addition, there has been no economic incentive to find safer pharmaceutical alternatives. There is a conservative alternative to overuse of corticosteroid medications, though, and it is found with CIM/TCM.

Today, more and more informed patients are taking a proactive approach and realizing the need for patient involvement in evaluation of risk versus benefit in pharmacological and surgical intervention. Patients are also becoming increasingly aware of the large amount of scientific study affirming the effectiveness of Complementary and Integrative Medicine, with acupuncture, herbal and nutrient medicine now achieving a high level of evidence-based medical efficacy. There are safe conservative therapies to consider before starting a chronic dependency on corticosteroid medication, or to reduce the adverse effects of multiple corticosteroid medications, or the need for increasing dosage and frequency of use. An informed and proactive patient can avoid the adverse consequences of steroid medication.

How synthetic corticosteroids harm your health

Since there are a number of corticosteroid hormones produced naturally in the body, and the production of these natural corticosteroids depends upon a strong and complex feedback regulation, the taking of a particular synthetic corticosteroid will inhibit various other natural corticosteroid functions. The synthetic corticosteroid will send a signal to the body tissues and organs that there is less need for natural production of the steroid hormones. Since the synthetic corticosteroid is different than the natural corticosteroid produced by the body, the drug does not effect corticosteroid receptors with the same array of effects of natural corticosteroid. This results in a lack of important natural corticosteroid effects and regulation in the body as the synthetic corticosteroid supplants the natural hormones. These two effects account for a wide array of potential health problems, many that routinely go unnoticed.

The body utilizes corticosteroid chemicals to regulate and control many processes in the body, immune, metabolic, and neurological. When the natural corticosteroid metabolism is supplanted, a wide variety of problems occur. This important systemic regulation needs a constant modulation of corticosteroid levels, and this is achieved via a complex feedback endocrine modulation, utilizing the hypothalamic CNS regulation equally with the adrenal responses of the kidneys, and many systems in between. This complex daily, and hourly diurnal, regulation and modulation of corticosteroid levels, is called the hypothalamus pituitary adrenal (HPA) axis, which implies that there are a number of other hormonal organs and tissues involved within our bodies along this axis of complex feedback regulation and modulation. Depending upon the patient's health history, this effect could be dramatic or go unnoticed. In addition, since the hormonal or endocrine system operates on an elaborate feedback mechanism, and many hormones are converted to other hormones as needed in this system, the other steroid hormones in the body will potentially become deficient or levels imbalanced over time. The adverse effects of synthetic corticosteroid, or glucocorticoid, use mainly come from this induced hormonal imbalance in the hpa axis. This is the reason that diabetes is a common side effect, since the pancreas is an endocrine gland and insulin and glucagons are steroid hormones. In addition, a study at the Dept. of Pharmacy and Therapeutics at the University of Pittsburgh (PMID:16901792), found that: "Hyperglycemia occurs in a majority of hospitalized patients receiving high doses of corticosteroids." This effect is seen in corticosteroid injections as well as oral dosing.

The most common type of corticosteroid, the asthma inhaler, has acquired a number of warnings from the FDA in recent years. Many of the inhalers now prescribed combine long-acting beta-adrenergic inhibitors with corticosteroids to increase the effectiveness. Inhibiting beta-adrenergic response quiets the bronchial spasms, while direct corticosteroid application inhibits the inflammatory swelling of the bronchioles. Government warnings state that even though these medications may decrease the frequency of asthma episodes, they may make episodes more severe, and in some patients, these severe episodes have ultimately ended with a fatal asthmatic event. Studies have shown that patients have increased the frequency of use of these inhalers, increasing the risk of severe episodes. This points to the fact that for many patients, frequency of asthma attacks have also increased with use. The physiological reason that the asthma has worsened with use is that the body's natural hormone reactions are being inhibited. A new type of asthma medication, Alvesco, was created to help with the problem of adrenal damage from chronic use of asthma corticosteroid albuterol. This new version is designed to inhibit release into full circulation by requiring a metabolic step to activate the corticosteroid. Alvesco was created due to clinical studies showing widespread injury to adrenal health with chronic use of corticosteroids.

Cortisol is our body's natural adrenal corticosteroid, and is integral to many aspects of our health. Cortisol has a diurnal rhythm and when this day to night rhythm of secretion is upset, poor sleep and insomnia, and daytime feeling of fatique or sluggishness occurs. Cortisol is also found to be integral to many aspects of neurotransmitter regulation in the brain, especially concerning the neurohormonal control exerted by the hypothalamus, which regulates the hormone stimulating hormones of the pituitary. Cortisol imbalances are associated with thyroid problems, metabolic syndrome, and a host of tissue problems. The chronic use of corticosteroid medication may have a dramatic effect on diurnal cortisol levels in the body.

The number of common health problems potentially caused by chronic use of corticosteroid medication

The effects of long term use of corticosteroid therapy has been well documented. For example, studies at the Albert Einstein College of Medicine in New York (PMID:1682792) showed that: "Long-term low dose corticosteroid use may reversibly decrease B-cell counts and specific antibody responses." While this may produce desirable effects with specific symptoms, it may also produce many undesirable effects on the whole immune response in your body, with increased risk of other diseases and infections. The risk of tuberculosis dissemination and fungal overgrowth, such as candidiasis is well documented. Concurrent prescription of prednisone with antifungal medications is prohibited in guidelines, and warnings concerning prescription of even short courses exist for patients with current infections and immunodeficiency are clear current prescribing guidelines, but often ignored. While the immune inhibiting effects with low dose prescription with corticosteroid asthma inhalers and topical corticosteroids may be mild, they do exist. With chronic use, even low-dose corticosteroid use can eventually cause neuropsychiatic symptoms and steroid myopathy (muscle dysfunction). Failure to seriously address risk versus benefit is now common. Ignoring these adverse effects is absurd, and working to restore a healthy homeostasis with CIM/TCM to decrease long-term dependence sensible, but largely discouraged in standard medicine.

FDA warnings state that "all corticosteroids increase calcium excretion." The medical faculty of the University Hospital Clinics in Barcelona Spain (PMID:8941496) concluded that: "Osteoporosis is one of the most serious adverse effects experienced by patients receiving long term corticosteroid therapy." This adverse effect can quickly lead to osteoporotic bone fractures that are both painful and debilitating. Inflammatory bowel conditions and relative lack of weight bearing exercise may increase the risk of corticosteroid induced osteoporosis, and postmenopausal women are particularly at risk. The most rapid bone loss occurs in the first 12-24 months after starting corticosteroid therapies (PMID:10769436). Steroid use has been found to cause fat cell enlargement resulting in blockage of veinous blood return in bone and leading to bone deterioration and small fractures (Univ. of Washington Radiology, click here: www.rad.washington.edu/maintf/cases/unk54/answers.html).

Does a regimen of calcium supplements with vitamin D prevent this osteoporosis? A large study by the Womens' Health Initiative in 2005 showed little if any effect from this regimen in prevention of osteoporotic fractures in menopausal women, yet a military study showed that large dosage supplementation decreased incidence of stress fractures in young healthy women undergoing strenuous training. This seems to suggest that utilization of the supplements is the key, with hormone deficient women showing problems in utilizing calcium supplements. This is because calcium is the most regulated nutrient in the body. Utilization of calcium to replenish bone is difficult with hormonal imbalances, and corticosteroids contribute to hormonal imbalances. A stronger and more effective protocol to prevent calcium depletion and osteoporotic fractures is needed for these patients, and a simple dependence on a small dose of Vitamin D and calcium supplement is not enough insure protection when taking corticosteroids. Utilizing the knowledge of the Complementary and Integrative Medicine (CIM/TCM) physician and integrating this with standard care may be very important for the patient with hormonal imbalances such as menopause.

Corticosteroids are also a major cause of osteonecrosis and avascular necrosis, which affects an increasing number of relatively young individuals each year, often goes undiagnosed, and predisposes one to an early need for hip replacement. Corticosteroids may upset the homeostasis of bone replacement, and health of the osteocytes, or may affect the fat, or lipid, metabolism, resulting in hypoxia and poor vascularity. Calcification of the arteries in the bone is another possible explanation for these pathologies, which almost always affect the end of the long bones at the hip or shoulder. These various routes of dysfunction have made scientific study of the corticosteroid-induced osteonecrosis unclear. Young patients, especially young women, are increasingly diagnosed with avascular necrosis, usually in the hip joints, and this could be attributed to prescription of corticosteroid medication.

Cataracts are also a frequent side effect of corticosteroid use. The incidence of cataracts in the normal population is 0-4%, but in chronic users of steroid therapies at moderate dose, 30-40% are found to get cataracts, and over 80% will acquire cataracts at high long-term dosage (National Institute of Neurological Diseases and Blindness, NIH grant, Washington Univ. School of Medicine, St. Louis Mo.) Other eye pathologies are also associated with corticosteroid medications, including diabetic retinopathy and glaucoma, as well as inflammatory disorders from fungal, viral and other microbial infections, often low-grade, that are poorly controlled when the immune system is impaired with corticosteroid use.

Studies have also linked chronic use of inhaled corticosteroids to such common problems as snoring and sleep apnea. A 2002 study at the University of Wisconsin School of Medicine and Public Health, cited below, found that there was an association of high risk for obstructive sleep apnea for patients using inhaled corticosteroid medications habitually for asthma control. Obstructive sleep apnea also has a high association of risk in cardiovascular medicine for heart attacks and strokes. While simply stopping the use of coricosteroid inhalers is not possible for most asthma patients, the decrease in the chronic use of these corticosteroids is possible by utilizing Complementary Medicine to calm symptoms, promote healing of the bronchiole membranes, and improve immune responses over time.

Studies in 2006 showed that chronic corticosteroid use could cause increased calcification of arterial walls, or "hardening of the arteries". Atherosclerotic plaque is the major risk factor in cardiovascular disease, contributing heavily to strokes and heart attacks, embolisms, and arterial bleeding. This plaque deposit starts with accumulation of calcium around areas of inflammation. A study at the University of Manchester, in England (cited below), found that a common corticosteroid medication caused calcification of the arterial wall.

Psychological effects are also seen in alarming frequency, and usually discounted in standard medicine. The Department of Psychiatry and Behavioral Sciences at Stanford University in California (Flores and Gumina 2005) documented the common occurrence of neuropsychiatric sequelae of effects from steroid treatment, though, and warned that these effects occurred in a significant percentage of patients with even short courses of high dose corticosteroid prescription. Despite these steroid-induced psychiatric symptoms being reported in medical scientific literature since the 1950s, the authors found almost no actual studies of these problems. Their research largely depended on analysis of case studies and other meta-analysis, as well as a number of small studies. Standard medicine is loathe to perform large studies concerning neuropsychiatric effects of corticosteroid prescription. Nevertheless, these researchers found that the literature defines clinical classification of 4 degrees of clinical symptoms in response to corticosteroid prescription, and found that a dose-dependent occurrance of serious psychiatric reactions occurred in 1.3% of patients with a low dose, and 18.4% of patients with a high dose prescription. The specific symptoms in a grade one reaction included a sense of euphoria and energetic stimulation, in grade two effects a hypomanic state with impaired judgment and insomnia, in grade three effects anxiety, phobia, obsessional thoughts, hypomania or depression, and in grade four effects hallucination, delusion, and extreme variations in mood. Clinically, these problems are oftened reported by the patients, but usually not considered with merit, often dismissed, and not considered as a cause to discontinue therapy. Instead, anti-anxiety and anti-depressant medications, or even anti-seizure and anti-psychotic medications, are routinely prescribed to counter these side effects.

The researchers at Stanford University concluded that: "First, the neuropsychiatric complications of steroid treatment are quite common. Second, the specific types of neuropsychiatric impairments comprise a range of symptoms from anxiety, irritability, and impaired cognition to depression, mania, psychosis, and suicidality. Third, although the available literature fails to reveal a uniform approach to treatment of these specific side-effects, it is clear that these symptoms are common enough and potentially very severe so as to warrant agressive and early intervention by psychiatric consultants (even when the medication is discontinued). Lastly, given the overall lack of published scientific literature on this topic, it behooves patients, family, and care-providers to work to improve the promulgation of this knowledge (of ignored neuropsychiatric side effects) with the goals of stimulating further research on this subject as well as improving the quality of care for patients with this condition." These respected medical doctors and medical school educators indicate the need for change, and warn of the widespread ill effects of corticosteroid prescription as it becomes more and more routine in our society. The utilization of Integrative and Complementary Medicine (CIM/TCM) in alleviating these neuropsychiatric side effects and chronic problems from corticosteroid administration should be an important consideration, especially since standard medicine is loathe to even acknowledge the problems and side effects. To see a 2013 follow-up meta-review of these neuropsychiatric adverse effects of corticosteroid use, by experts at the University of Calanzano School of Medicine, in Italy, click here: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3853679/ . The conservative conclusion was that: "The use of corticosteroids is strongly associated to the development of psychiatric/neurological side effects. These effects are due to the wide expression of GR (glucocorticoid receptors) in the brain, and their long-term modulation can lead to functional and anatomical alterations, which might be responsible for the observed side-effects." The recommendation was to start acknowledging and reporting these adverse neuorpsychiatric effects to finally address these serious consequences of corticosteroid use and provide better guidelines for use and discontinuation that stops treating all patients with a one-size-fits-all set of drug guidelines.

How concerned is your doctor about long term risks and health problems caused by corticosteroid therapies?

Are patients on corticosteroid therapies being monitored for long term side effects? There are few reports of systems of monitoring for side effects after administering these therapies. There are few reports of studies on the follow up of corticosteroid therapies, especially in the United States. In Australia, a study was conducted at the Universtity of Tasmania School of Pharmacy (PMID:10886467) and concluded from a randomized review of 212 patients consecutively admitted to a large hospital and receiving long-term corticosteroid therapies, such as inhalers, oral meds, or injections, that less than 20% of these patient were being tested for bone density decreases and less than half had had blood glucose tests administered in the last year. There is little data to show any follow up in the U.S.

The use of steroids in the United States, despite long years of warnings from research, has continued to increase. Even over the counter products, including beauty products, now routinely use synthetic steroids without having to print warnings. A 2010 article in the New York Times outlined how skin lighteners have brought many patients to the medical clinic with alarming problems. The article outlines how steroids added to the creams upset the immune and hormonal responses in the body, producing thin skin, bruising, stubborn acne, and other side effects. The synthetic steroids are listed as ingredients, but there are so many different chemicals now that the names on the ingredient lists mean nothing to the consumer. Clobetasol propionate is one of the steroids mentioned in the article, which is a potent synthetic steroid, but the label only states that the product should be used only as directed by a physician, even though it is sold over the counter. Counterfeit health and beauty products are also becoming common, and use of synthetic steroids in these products is now common to increase immediate effects. The consumer in the United States may be taking an array of low dose synthetic corticosteroids unwittingly.

The list of contraindications with other medications when prescribing corticosteroid medications is large. FDA guidelines list 20 different classes of medications that may cause problems when concurrantly taken with corticosteroids. This list includes potassium depleting antibiotics and diuretics, macrolide antibiotics, anticoagulants, antidiabetics, NSAIDS, anticholinesterases, antitubercular drugs, other corticosteroids (e.g. bupropion), which can lower the seizure threshold with concurrant use, antiseizure medications such as phenytoin, cyclosporine, digitalis, synthetic hormone therapies with estrogens, including oral contraceptives, and the psychiatric drug quetiapine. In addition, corticosteroid use may suppress reactions in skin tests, making evaluation of TB or allergies problematic, and may result in a diminished response to vaccines. The size of this list is so long that it is routinely ignored.

Cortisone shots for the relief of joint pain

One of the most prevalent uses of synthetic corticosteroids is the cortisone injections commonly used to treat joint pain. An October 28, 2010 article in the New York Times Health section reviews the history of these injections, and new light shed on the efficacy versus harm from cortisone injections revealed in a British Lancet article on 45 randomized trials of cortisone injections and long-term outcomes. It appears that, while these injections bring short term partial relief of pain to about 63 percent of patients, the vast majority of the patients studied had worse long-term outcomes after 6 months than those that received no treatment. The patients receiving cortisone shots also had a 63 percent increased incidence of relapse, and multiple cortisone injections produced a 57 percent worse outcome than a single injection. The senior author of the study, Bill Vicenzino, the chairman of sports physiotherapy at the University of Queensland in Australia, stated that many orthopedists routinely prescribed cortisone injections as a wait-and-see therapy, to see if the injury healed on its own after 6 months, with temporary relief provided by multiple cortisone injections, but that it appeared that the cortisone injections impeded the healing. This type of therapy often supersedes actual physiotherapy on the injured tissues. The study authors stated also that the injections were warranted because the stated diagnosis was usually tendinitis, implying that there was an underlying inflammatory problem, whereas in reality, there was a degenerative tissue problem in most cases. In other words, the therapy of choice was dictating the diagnosis. This is common practice in medicine today, and too often, this is because the insurer only pays for the cortisone injection, and routinely rejects actual tissue therapies, and even testing to determine the actual diagnosis, such as an MRI. You may click on this link to read the article: http://well.blogs.nytimes.com/2010/10/27/do-cortisone-shots-actually-make-things-worse/?src=me&ref=general

Further review of the efficacy of corticosteroid injections in 2015, by the U.S. AHRQ (Agency for Healthcare Research and Quality) concluded that from a review of all high quality scientific studies and randomized controlled human clinical trials (RCTs) that "epidural corticosteroid injections for radiculopathy were associated with immediate improvements in function, but benefits were small and not sustained, and there was no effect on long-term risk of surgery. Evidence did not suggest that effectiveness varies based on injection technique, corticosteroid, dose, or comparator. Limited evidence suggested that epidural corticosteroid injections are not effective for spinal stenosis or nonradicular back pain and that facet joint corticosteroid injections are not effective for presumed facet joint pain. There was insufficient evidence to evaluate effectiveness of sacroiliac joint corticosteroid injections." In other words, they provide no real value except a short period of mild improvement of function that could facilitate actual physiotherapy. Another meta-review of all studies and 32 RCTs of corticosteroid injections for low back pain, by the Oregon Health and Science University, and published in th August 2015 Annals of Internal Medicine, found that these injections presented only mild temporary pain relief for patients with herniated discs, and no benefit over placebo for spinal stenosis, repeating the findings of the 2010 British study cited above. These researchers also found evidence of study bias in selection of patients for the RCTs that tilted the study findings in favor of steroid injections. The denial of proven treatments combining acupuncture and physiotherapy for many years, while the number of ineffective corticosteroid injections skyrocketed, does not have the benefits to patients as the chief concern.

In 2012, corticosteroid, or cortisone shots, became an issue of national concern when it was discovered that the pharmaceutical industry had created a way to avoid FDA regulation and safety in the manufacture of injectable corticosteroid by using large so-called compounding pharmacies. One of these large manufacturers, the New England Compounding Center (NECC), in Massachusetts, distributed at least one batch of methylprednisone corticosteroid injection solution that was contaminated with a fungus that was deemed responsible for hundreds of hospitalizations of patients with fungal meningitis, and at least 35 deaths. The FDA Center for Drug Evaluation and Research Office of Compliance reported that the fungus Aspergillus fumigatus was identified in the batch of tens of thousands of injectable solution vials, and that foreign material was also observed in other vials from the company. The manufacturer was shut down and a large recall of lots of the injectable solution sent to California, Connecticut, Florida, Georgia, Idaho, Illinois, Indiana, Maryland, Michigan, Minnesota, North Carolina, New Hanmpshire, New Jersey, Nevada, New York, Ohio, Pennsylvania, Rhode Island, South Carolina, Tennessee, Virginia, Texas, and West Virginia, was ordered. Compounding pharmacies are intended to be small pharmacies that provide individualized compounds of medicines to doctors as ordered, not manufacturers of very large lots of pharmaceuticals. The NECC was reported to be not accredited by the Pharmacy Compounding Accreditation Board, but the supposed compounding pharmacy had been created in 1998 and was licensed. A number of serious complaints had been filed and investigated over the years, including distribution of compounded methylprednisone acetate solution without the required doctor's prescription. Company memos indicated that the Massachusetts Pharmacy Board and FDA had apparently not inspected the company facilities. A sales staff of dozens of marketers aggressively marketed the corticosteroid injections by NECC and its sister company Ameridose. CBS News reported that the owners of NECC also operated a large recycling company within the same warehouse, and that a large fire in 2009 was captured on video and showed black smoke billowing from the back of the building that housed NECC. The Governor of Massachusetts demanded that the lead pharmacist of the sister company to NECC, Ameridose Sterile Admixing Services of Wesborough, Massachusetts, resign from the Massachusetts state board that oversees pharmacies, but that she refused to step down, despite questions of impropriety, since NECC had received almost no disciplinary action from numerous complaints since 2002. In the meantime, Ameridose itself came under scrutiny and completely shut down its operations when unsafe and nonsterile manufacturing conditions were discovered on preliminary inspection. The closure agreement included the sister company Alaunus Pharmaceutical as well. Whether these alarming findings of unsafe impropriety extend to other manufacturers of corticosteroid injections is being investigated.

In 2014, a U.S. FDA panel of experts voted to issue stern warnings on certain types of corticosteroid injections. The panel voted against a recommendation to issue a black box warning that all corticosteroid injections posed risks that outweighed benefits, but agreed 15 to 7 that injections of corticosteroids near clusters of small arteries in the neck carried higher risks than were previously considered, especially is a type of corticosteroid with a more granular texture were used, creating a significant risk of blocking blood flow in an artery. Administration of corticosteroid injections has risen in the United States to an estimated 4-6 million per year, according to Dr. Laxmaiah Manchikanti, chairman of the American Society of Interventional Pain Physicians, who stated in a New York Times interview that the injections addressed by the FDA panel should probably just be banned, stating: "It is very high risk, and so far there is no evidence that it works." Dr. William Landau, a professor of neurology at Washington University Medical School, in St. Louis, Missouri, U.S.A. stated in the article that he believed that the broader category of epidural corticosteroid injections should have receive the sternest black box FDA warnings, as there was little evidence that they reduced pain, and significant adverse effects. Dr. Landau was quoted: "There's no positive excuse for injecting this stuff except for the profits". With perhaps six million injections per year and rising, though, the profits are now enormous, as is the cost to the government and payors of insurance premiums. While this broad FDA warning was voted down this time, the implications are clear. Whether corticosteroid injections will decrease in use, and safer and more beneficial therapies, such as acupuncture and physiotherapy, will be encouraged and prescribed by medical doctors, is the question patients should be asking.

The public has become curious about corticosteroid injections after these alarming scenarios, and the facts concerning these injections are almost as alarming as the cavalier production and manufacturing practices. The New York Times reported in an article of November 18, 2012, entitled How Back Pain Turned Deadly, that the frequency of corticosteroid injections dispensed to Medicare patients more than doubled from 1997 to 2006, rising 121 percent. In Washington State, perhaps the most concerned with excessive overuse of pain medication and steroid drugs, a study found that the use of corticosteroid injections for back pain rose 12.6 percent between 2006 and 2009, costing the taxpayers $56 million, with many patients receiving up to 10 shots in a year, despite guidelines that limit the use to 3 injections in one joint area. Another study, by the American Society of Interventional Pain Physicians (L. Manchikanti) found that the number of corticosteroid injections for Medicare patients increased 159 percent from 2000 to 2010. Dr. Janna Friedly, a researcher at the University of Washington, was quoted: "There are lots of places doing lots of injections for conditions that haven"t been shown to benefit (from studies)". The Times reports that most academic researchers say there is no evidence that steroid injections are useful in easing straightforward chronic low back pain, and that immediate effects could be attributed to the local anesthetic that is mixed with the corticosteroid. Dr. Friedly stated that "There's a lot of concern about perverse financial incentive.", as much of the corticosteroids are administered at clinics owned by the prescribing physicians. With a typical pain clinic providing 5000 injections a year, and reimbursement ranging form $200 to $600 per shot, this is an income stream of $1-3 million per year. While government and private insurers freely approve payment for corticosteroid injections, there has been a widespread denial of payment for sound conservative physiotherapies such as acupuncture and soft tissue mobilization. The cost of a course of such treatment would be less than a single corticosteroid injection in many cases.

To test this theory of many experts that it is the local anesthetic that provides relief with epidural corticosteroid injection, Dr. Steven P. Cohen, at Johns Hopkins School of Medicine, in Baltimore, Maryland, U.S.A. conducted at randomized controlled human clinical trial in 2013 that showed that a simple injection of saline solution and local anesthetic performed just as well as an epidural corticosteroid injection, providing modest pain relief when the low back pain involved inflammation around the spinal cord or nerve root for up to 2 months. This clinical trial be Dr. Cohen was apparently the first to compare the effects of epidural corticosteroid, which is usually injected in a solution of saline solution and anesthetic, to saline solution and local anesthetic alone (Anesthesiology Oct. 2013; Vol. 119(4): 907-931). It appears that the vast number of epidural corticosteroid injections, and their adverse effects, could have been easily avoided. Dr. Cohen also published a study in the 2011 British Medical Journal that caudal epidural injections of saline alone performed nearly as well as caudal corticosteroid epidurals. Dr. Cohen was concerned that of the 35 controlled studies evaluating corticosteroid epidural injections for pain, that only about half of the studies showed benefit, and most of the studies that showed benefit were conducted by medical doctors that routinely used corticosteroid epidural injections in practice, while those that did not use them were more likely to find that they didn't work. The continuing study of Dr. Cohen suggested that epidural injections with saline solution or saline and local anesthetic could provide the modest pain relief in inflammatory neurogenic low back pain and could be used instead of the problematic use of corticosteroid injections.

The proof that acupuncture and herbal medicine does have sufficient evidence-based effects to treat chronic inflammatory conditions

A growing body of evidence from scientific study is confirming not only that acupuncture has proven efficacy to treat chronic inflammatory conditions, but how this needle stimulation works. Acupuncture is difficult to assess under the double-blind placebo-controlled conditions used to prove efficacy of corticosteroid pharmaceuticals, yet has been held to this standard. Creating an acupuncture placebo is problematic, and blinding both the administering physician and the patient to this so-called placebo versus real acupuncture has been a challenge. Acupuncture, in effect, has been held to higher standards of proof than any other manual therapy. Despite this, the NIH and WHO have reviewed evidence over decades and long ago declared that acupuncture is a proven evidence-based therapy for many chronic inflammatory conditions. Meta-analysis since then has shown that success in human clinical trials has been demonstrated in the treatment of rheumatoid arthritis, bronchial asthma, pruritic dermatosis, carpal tunnel syndrome, and other inflammatory disorders in humans and animals (SCOGNAMILLO-SZABO, BECHARA, 2001). Specific trials in recent years have confirmed the efficacy of acupuncture treatment on allergic rhinitis, bronchial asthma, eczema, rheumatoid arthritis, and other chronic inflammatory disorders (TOWNSEND et al 1999; TUMACHI 1999, CASIMIRO et al 2002, STERUER-STEYA, RUSSUB, STEURERC, 2002; BIELORY, HEIMALL, 2003, MADSEN et al 2003; MCCARNEY et al 2004). Each year clinical study is advancing and producing greater proof of the efficacy of acupuncture.

How does acupuncture control chronic inflammatory conditions? Since the inflammatory response involves a complex set of highly orchestrated events in the body, with a cascade of chemical mediators insuring a highly regulated and modulated effect, this is a difficult question to study. The initial response to tissue injury and disease is largely controlled by the hormone cortisol, which is constantly produced mainly by the adrenal glands in a controlled diurnal cycle. Many health problems, especially hormonal imbalances, can adversely affect the diurnal cortisol levels and responses. Corticosteroids are synthetic chemicals that mimic this hormonal inflammatory mediator. There are many other inflammatory mediators in the body besides cortisol. Prostaglandins and interleukins are inflammatory mediators that are inhibited by non-steroidal anti-inflammatories (NSAIDs). The problem with these pharmaceutical approaches is that when the whole cascade of inflammatory mediators is not addressed by the therapy, and that severe inflammatory dysregulation can occur, with disastrous results. Since the inflammatory process is a beneficial process in the body, evolved to repair and maintain healthy tissues, inhibition of a part of the process can produce unwanted results. The trials of malpractice and medical injury concerning the anti-inflammatory COX2 inhibitor, Vioxx, revealed that chronic use of this medication resulted in perhaps 50,000 deaths related to inflammatory dysregulation. The promise of acupuncture is that is may stimulate the whole natural cascade of inflammatory mediators in the body, and thus avoid these dangerous and unwanted side effects. More and more scientific studies and randomized controlled clinical trials confirm the positive effects of specific acupuncture and electroacupuncture stimulations on restorative modulation of the expression of inflammatory mediators. This homeostatic restoration is the type of effect that we need, as the body will heal itself and prevent disease effectively if it works optimally.

Many sound scientific studies prove the effectiveness of acupuncture stimulation in this regard. For example, a 2005 study on animals at University Medical Schools and Veterinary Schools in Sao Paulo, Brazil, (Szabo et al, Sao Paulo State University and University of Sao Paulo, Faculty of Medicine, funded by ELISA and FAPESP), investigated the more specific effects of inflammatory modulation with acupuncture. Previous studies had demonstrated that acupuncture significantly suppressed neutrophil migration to the site of induced inflammation in the peritoneal cavity of study animals. Neutrophils are white blood cells that are the main immune reaction to acute infection and inflammation, and the peritoneum is the lining of the abdominal cavity. It was found that this acupuncture effect was not mediated by corticoid adrenal hormones, because a drug that blocked the corticoid receptors, RU-486, did not interfere with the immune response. Three cytokines, or inflammatory mediators, tumor necrosis factor alpha (TNFalpha), interleukin-1 beta (IL-1beta), and interleukin 10, were measured. It was found that acupuncture stimulation from just 3 needles distally placed, significantly inhibited just the interleukin-1beta, an important cytokine that stimulates neutrophil migration in the inflammatory complement system in humans. The researchers found that acupuncture stimulation exerts a modulatory effect on inflammation, and that specific effects are probably also tied to specific acupuncture locations on the body. In this study, the sites were between the eyebrows (Yintang), at the lumbosacral junction (DU3), and near the anus (DU1). As with all such studies, the choice of acupuncture points and stimulation was designed for simplicity, and was probably less effective than many clinical acupuncture treatments commonly performed. For example, in 2012, research at the Beijing University of Chinese Medicine, in China, showed in a randomized controlled study that either electroacupuncture or manual stimulation at just one very common point on the leg, ST36, effectively downregulated excessive pro-inflammatory cytokines such as IL-1beta and TNF-alpha, which are implicated in many chronic inflammatory disease states. The modulatory effects included upregulating the expression of the anti-inflammatory IL-2 cytokine in the laboratory animals with induced chronic arthritis (PMID: 23140046). These studies also point out that actual stimulation of the needles to elicit responses are important, and the widespread belief in the United States that you shouldn't feel anything, discouraging actual stimulation over just the insertion of the needle is proven to be a mistake.

The implications of these studies, and numerous other scientific studies of anti-inflammatory, or inflammatory modulation effects of acupuncture, are that acupuncture stimulation is now proven to have an array of effects that modulate chronic and acute inflammatory states, and that these various effects stimulate an improved natural response in the body to inflammation. These studies also imply that various types of point selection and stimulation techniques are proven to have specific effects. In short, the empirical evidence collected over centuries in China concerning the application of acupuncture are proving true, based on modern laboratory measurement and modern scientific method. While corticosteroids do produce strong synthetic effects on the immune inflammatory mechanisms, acupuncture, and herbal and nutrient medicines, provide a restoration of the normal corticosteroid effects and alternate natural inflammatory modulation. Use of bioidentical hormone therapies, aids to adrenal health and the immune system, balanced essential fatty acids, antioxidant chemicals, and numerous other therapeutic tools can achieve the same goals as corticosteroid use, and the only side effect is better overall health.

Anti-inflammatory effects of Chinese herbs are the subject of numerous well-funded studies and clinical trials in the United States, as well as China, many European countries, Japan, Australia, Brazil, etc. One only needs to go the U.S. National Institutes of Health (NIH) Pub-Med database to access many of these scientific studies. The important points we see elucidated in herbal studies are that the effects are dose dependent, that the choice and quality of herbs are important, and often that the extraction methods are important to achieve the correct chemicals. The way to insure that these objectives are achieved is by utilizing professional herbalists and their professional products. Most of these highly trained professional herbalists in the United States are Licensed Acupuncturists.

The key point when examining scientific evidence of the anti-inflammatory effects of acupuncture and Chinese herbs is the difference between the use of steroidal and non-steroidal synthetic medicines and the effects of acupuncture and Chinese herbs. The pharmaceutical approaches are specific and allopathic, meaning that the chemicals are designed to alter specific mechanisms in the inflammatory cascade. Often, these inflammatory cytokines and other chemicals in the cascade of biochemical events are not acting in just one way, though, with a single important cytokine, such as nuclear factor kappa beta (NFK-b), considered the "holy grail" of chronic inflammatory diseases, shown to exert both pro-inflammatory and anti-inflammatory effects, depending on the array or environment of the immune chemicals interacting with it. By designing allopathic drugs to block expression of NFK-b, we obviously produce unwanted and adverse effects. Acupuncture and Chinese herbs have been shown to have similar effects, but in a modulatory and varied manner, stimulating areas of the complex inflammatory cascade that may not be working efficiently due to some health problems in the body. The centuries of evolution of these chemicals in herbs have interacted with the human organism to achieve a modulatory effect. The chance of side effects with the latter approach are slim, and the possibility of restoring the patient metabolisms are great. In addition, most inflammation modulating herbal extracts are composed of a number of synergistic chemicals, producing synergistic effects, such as antioxidant and detoxification effects, and protective effects in the tissues. The endproduct of therapy should be a healthier immune system, which is achieved with Complementary Medicine, whereas the chronic use of synthetic corticosteroids has been found to have negative effects on the whole immune system, especially in producing adrenal insufficiency, which would negatively impact the ability to respond to future inflammation and infection. Acupuncture and Chinese herbs may also be varied and individualized for each patient and treatment, producing individualized effects that the physician can choose in response to a changing condition of the patient. Allopathic medicines are usually taken at the same dosage and not varied, regardless of the changing nature of the condition. These two strategies are not really at odds, though, but should be integrated to achieve a more thoughtful and efficient course of treatment. The last significant advantage of the acupuncture and Chinese herbs is that the treatments can also be expanded to stimulate improved adrenal and immune function, producing future indirect benefits for the patient.

Patient choices in the treatment of inflammatory disease

What are the considerations when discussing this type of therapy and what are the more conservative therapies that you can try? Risk versus benefit and lowering dosage are important considerations that should be included in your discussion. Monitoring for serious harm should be adopted on a schedule. The ultimate decision on whether to take these medications always lies with the patient. Never abruptly stop corticosteroid therapies, because the body needs to respond by starting to increase the natural production of these hormones. Safer conservative therapies can be tried and you can see for yourself whether you are making progress with these therapies. Scientific study has confirmed the efficacy of both herbal medicines and acupuncture in the role of inflammatory regulation and modulation, but the best approach is often to combine a variety of therapies to specifically address both the symptoms and underlying causes of chronic inflammatory and rheumatic conditions. This includes herbal prescription, improved diet and lifestlye, dietary supplements, physiotherapies, and acupuncture. The expertise and ability of the therapist administering these therapies is all important, as well as the attention of scientific study and evidence-based medicine. Herbal therapies, acupuncture, and physiotherapies are complicated subjects and there is much variation in the outcome depending on the skill of the practitioner. The choosing of the Licensed Acupuncturist if often very important, especially in more difficult diseases.

Choice of herbal medicine to treat chronic inflammatory and rheumatic conditions is also important. Many patients are swayed by internet sites that present herbal information and promote products with outlandish claims of benefit. Since the herbal industry is unregulated, commercial products should not be trusted for serious medical problems. Professional herbalists have access to products that are genuine and tested, since professional herbalists are much more demanding and educated in herbal science than the general public. These professional products may cost more than the discount products that are highly advertised, but this quality is essential to the cure. Physiotherapies may be very important in the overall treatment of inflammatory rheumatic conditions, but may be administered by therapists that have received only a few months of training. Hospitals and clinics often choose to hire the less trained physiotherapists for 'therapeutic massage'. On the other hand, a TCM physician, or Licensed Acupuncturist, may have advanced training in physiotherapies, and be able to apply this training better, due to the years of advanced education in pathophysiology received in the TCM medical school. Physical therapists are well trained but often emphasize only rehabilitative exercise rather than soft tissue therapy and passive manipulation. The TCM physician may or may not have advanced training in physiotherapy, called Tui Na in China, and this too should be a consideration when choosing an acupuncturist. Acupuncture outcome, too, is completely dependant on the skill of the practitioner. While the act of needle insertion is simple, the obtaining of a response is a subtle and complicated process that depends on both the manual skills of the acupuncturist and the attention to the responses of the individual patient to the needle manipulation.

Hopefully, you can arrive at a course of therapy that is both safe and beneficial. You may choose to try safer conservative therapies before resorting to corticosteroids, or you may be on corticosteroids and try to see if you can have success with safer conservative therapies and gradually reduce your use of these potentially harmful corticosteroids. Either way, I hope this handout had helped you to make these important decisions.

One more note: many patients feel that the steroid asthma inhalers and medications must be safe because of the widespread use. Clembuterol, an asthma medication similar to albuterol, is used by professional athletes and bodybuilders to promote muscle growth. This steroid inhaler has the same strong effects that other steroids have.

Information Resources / Additional Information and Links to Scientific Studies

NOTE: many links to scientific studies confirming the anti-inflammatory effects of herbal medicine and acupuncture are available on articles from this website related to the specific inflammatory diseases. Below, some pertinent study links are provided as well.

  1. A 2012 study at the VU University Medical Center, in Amsterdam, The Netherlands, noted that treatment with standard synthetic glucocorticoids, or synthetic cortisols, such as prednisone, often resulted in suppression of the hypothalamic-adrenal axis and adrenal insufficiency. While these synthetic corticosteroids are important and effective drugs for serious disorders, the over-prescription of these drugs in standard medicine presents quite the remarkable potential for adrenal insufficiency: http://www.ncbi.nlm.nih.gov/pubmed/22592733
  2. A 2015 study in Thailand, at the Chulalongkorn University School of Medicine, showed that the prevalence of adrenal insufficiency treated at hospitals in the last year had reached a crisis level, and could be attributed to synthetic corticosteroid drugs found in over-the-counter medications bought from the drugstore: http://www.ncbi.nlm.nih.gov/pubmed/25614534
  3. A 2015 report from the Oddzial Psychiatry Clinic in Warsaw, Poland underscores the risk of psychosis and psychological pathology from treatment with high dosage of corticosteroids, such as Prednisone: http://www.ncbi.nlm.nih.gov/pubmed/26488344
  4. A randomized controlled human clinical trial of corticosteroid injections for chronic lateral epicondylalgia, or elbow pain, published in the Journal of the American Medical Association (JAMA Feb 6, 2013), and conducted by experts at the University of Queensland in Australia, found that these commonly prescribed injections provide no benefit over a placebo injection of saline water, even when physiotherapy is added to the protocol. It was argued that if physiotherapy was utilized after the injection, that the patient would be able to progress from the temporary relief of inflammatory symptoms and achieve better results from physiotherapy, but the benefits from physiotherapy were apparent and equal with either the placebo injection or corticosteroid: http://aapmr.eventmediaonline.com/media/114_Mautner_handout.pdf
  5. A large randomized controlled human clinical trial of corticosteroid injections for low back and lumbar pain, often with pain radiating down the leg, conducted at the University of Washington, Seattle, Washington, USA, and published in the esteemed New England Journal of Medicine, found that these commonly prescribed injections for lumbar pain provided no benefit over placebo, and no increased benefit when combined with the anesthetic lidocaine over lidocaine injection alone for temporary relief of pain. The lead author for the study, Dr. Janna Friedly, stated: "These (corticosteroid injections) are so commonly used and the steroids do pose an added risk to patients without much benefit." Physicians interviewed after these findings stated that they would probably continue to use corticosteroid injections routinely, despite evidence of adverse health effects and virtually no benefits: http://www.reuters.com/article/2014/07/03/us-spinal-stenosis-epidural-steroids-idUSKBN0F82CY20140703
  6. This website at Drugs.com supplies the standard FDA warnings concerning the corticosteroid medication prednisone: http://www.drugs.com/pro/prednisone.html
  7. This website of the National Health Service of the United Kingdom (Great Britain) shows that even a conservative set of warnings of potential adverse effects of corticosteroid use is alarming: http://www.nhs.uk/Conditions/Corticosteroid.aspx
  8. A 2006 study at the University of Oklahoma Health Sciences Center showed that use of oral corticosteroids in patients on long-term warfarin/coumadin therapy to control blood clotting and cordiovascular risk may result in significant drug interaction and alteration of the effective circulating levels of warfarin/coumadin, a potentially dangerous situation: http://www.ncbi.nlm.nih.gov/pubmed/17119104
  9. A 2002 study at the University of Wisconsin School of Medicine and Public Health found that chronic use of inhaled corticosteroid (ICS), such as asthma med inhalers, had a high association with risk of acquiring obstructive sleep apnea: http://chestjournal.chestpubs.org/content/135/5/1125.abstract
  10. A 2005 meta-review of the widespread use of corticosteroid medication in the treatment of children, by experts at the University College of London Hospital and Tavistock Centre, in London, UK, noted that adverse neuropsychiatric effects are common with use of all types of corticosteroids in pediatric care, including asthma inhalers, and that these are often ignored due the fact that these symptoms of adverse effects of the drugs may occur at any point during treatment, not just soon after starting the medication, and frequently occur due to withdrawal. The lack of serious studies of these adverse effects in 2005 made it nearly impossible to define actual incidence or prevalence, or to identify the risk factors. This lack of scientific evidence was attributed to dependence on randomized controlled human clinical trials that were very difficult to design and conduct in this population. Nevertheless, this conservative report outlines abundant evidence collected for over a half century of the potential and probable adverse effects, which are largely ignored: http://adc.bmj.com/content/90/5/500.fullhttp://adc.bmj.com/content/90/5/500.full
  11. Corticosteroid-induced osteonecrosis and avascular necrosis of the heads of the long bones (mainly the femur at the hip) with chronic use of corticosteroids has long been documented, and is the most common non-traumatic cause, according to the McGill Universitiy Health Center in Montreal, Canada: http://www.ncbi.nlm.nih.gov/pubmed/19429441
  12. The pathological mechanisms of corticosteroid-induced osteonecrosis and avascular necrosis of the heads of the long bones are poorly understood because of the wide array of negative health effects induced by chronic use of corticosteroids, including negtive effects on lipid metabolism, calcium metabolism, and coagulation pathways: http://www.ncbi.nlm.nih.gov/pubmed/21161435
  13. Surgeons at the University of Miami School of Medicine in Florida have noted a rise in the incidence of osteonecrosis of the femoral head at the hip in young individuals (primarily women) and note the association with corticosteroid use. These surgeons also note that most cases go undiagnosed until a late stage, by which time most therapy is no longer helpful, and a hip replacement is performed : http://www.jaaos.org/cgi/content/abstract/7/4/250
  14. A 2014 randomized controlled study at the Wuhan University School of Medcine, in Wuhan, China, showed that the Chinese herb Gastrodia elata (Huang lian), and an active chemical in the herb, Gastrodin, could prevent steroid-induced osteonecrosis of the femoral head: http://www.ncbi.nlm.nih.gov/pubmed/25421192
  15. A 2014 study at the China Academy of Chinese Medical Sciences, in Beijing, China, found that the Chinese herb Achyranthes bidenta, or Niu xi, could prevent steroid-induced osteonecrosis of the femoral head. Such study will help find a broader evidence-based protocol for prevention and treatment of this problem with corticosteroid use, utilizing CM/TCM: http://www.ncbi.nlm.nih.gov/pubmed/25471933
  16. A 2010 study at the University of Brescia in Italy reveals that glucocorticoid (corticosteroid) therapy is the most common cause of secondary osteoporosis: http://www.ncbi.nlm.nih.gov/pubmed/20938221
  17. A 2006 study at the University of Manchester in England found that chronic use of corticosteroid medication induced calcification of the arterial walls, or "hardening of the arteries": http://circres.ahajournals.org/cgi/content/short/98/10/1264
  18. A 2005 study at the Department of Psychiatry and Behavioral Sciences at Stanford University in California found that neuropsychiatric side effects of corticosteroid medications are common, usually ignored, have been insufficiently studied, and comprise a wide range of psychological effects that are deleterious and usually dismissed: http://www.dianafoundation.com/articles/df_04_article_01_steroids_pg01.html
  19. About.com, accredited by Health on the Net, provides the standard listing of side effects of the most prescribed corticosteroid, prednisone: http://ibdcrohns.about.com/cs/prescriptiondrugs/p/medprednisone.htm
  20. In 2005, the British Medical Journal (BMJ) presented a thorough article showing the array of adverse psychological effects with long-term use of corticosteroids in children and adolescents: http://adc.bmj.com/cgi/content/full/90/5/500
  21. Lymphomation.org presents a succinct review of the common adverse side effects of corticosteroids, which are broad, causing immune deficiency, depression, osteoporosis, high blood pressure and diabetes, to name just of few of the most prevalent serious consequences of chronic use or improper dosing and tapering in acute prescription: http://www.lymphomation.org/side-effect-prednisone.htm
  22. Respiratory Medicine vol.100, issue 8; 1307017 (Aug 06) presented a meta-review of evidence of adverse endocrine effects with corticosteroid medication in children: http://www.resmedjournal.com/article/S0954-6111%2805%2900510-X/abstract
  23. A 2014 review of the pathology of contact dermatitis as a systemic disease, but experts at the University Hospital Jena, in Germany, note that systemic contact dermatitis is now a common condition occurring in previously sensitized patients after re-exposure to any number of substances, chief among which are corticosteroids and various antibiotics, particularly aminoglycosides and penicillin derivatives. This produces diffuse exanthema, or redness in the skin folds, unfortunately given the term "Baboon Syndrome": http://www.ncbi.nlm.nih.gov/pubmed/24767189
  24. A 2009 study of the diverse effects of nuclear factor kappa beta (NF-kB), by Dr. Toby Lawrence of the Inflammation Biology Group of the Center for Immunology Marseille-Luminy, in Marseille, France, shows that this immune cytokine, frequently targeted in anti-inflammatory drugs, has been found in recent years to exert not only root pro-inflammatory effects driving many chronic diseases, but also anti-inflammatory cascades. The classic pro-inflammatory effects of NF-kB are triggered by microbial chemokines such as toll-like receptor ligands, and human immune cytokines such as TNF-alpha and IL-1b, often seen in chronic inflammatory diseases, but an anti-inflammatory pathway has been found that is not triggered by TNF-alpha, and is activated by lymphotoxin-8, CD40, and B cell activating factor, and dependent on interleukin kappa beta kinase types. In other words, key inflammatory chemokines and cytokines act in a modulatory manner, and treatment should also try to effectively modulate these key immune dysfunctions: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2882124/
  25. A 2014 review of current published studies of Chinese herbal medicines which exert potent anti-inflammatory effects, by the Icahn School of Medicine at Mount Sinai, New York, U.S.A., shows that many of these effects exert inhibition of the inflammatory NF-kB pathway and inhibit both the innate and adaptive immune proinflammatory cytokine responses in a modulatory manner: http://www.ncbi.nlm.nih.gov/pubmed/24252977
  26. A 2015 study at Zhejiang Chinese Medicine University, in Hangzhou, China, found that the important active herbal chemical Resveratrol, largely derived from the Chinese herb Polygonum cuspidatum (Hu zhang), exerts a modulating anti-inflammatory effects via a number of pathways, down-regulating the expression of inducible nitric oxide (iNOS), interleukin-6 (IL-6) and modulating the effects of nuclear factor kappa beta (NK-kB): http://www.ncbi.nlm.nih.gov/pubmed/25651848
  27. A 2007 study at the University of Maryland, in Baltimore, Maryland, U.S.A. and the Shanghai University of Traditional Chinese Medicine, in Shanghai, China found that electroacupuncture stimulation appears to have a strong and lasting effect in stimulating increased corticosterone levels in circulation in study animals where significant inflammation was induced by injection of complete Freund's adjuvant (CFA), a solution of antigen commonly used as an immunopotentiator in studies, but not in study animals without inflammation. This study also found that in study animals where the cortisone-producing adrenal glands were removed, that electroacupuncture did not produce the anti-edema effects seen in the animals with induced inflammatory swelling, but still produced measurable decreases in hyperalgesia, or increased pain sensitivity. This study showed that electroacupuncture works by stimulating natural homeostatic adrenal responses to treat inflammation, and does so in a homeostatic modulatory manner, but also stimulates other processes that are important in anti-inflammatory modulation, affecting the brain and modulating pain perception: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1976320/
  28. A 2008 follow-up study of electroacupuncture and anti-inflammatory mechanisms at the University of Maryland, in Baltimore, Maryland, U.S.A. showed that this stimulation activated the hypothalamus-pituitary axis to significantly increase ACTH (adrenocorticotropic hormone) and suppressed inflammatory edema via ACTH and CRH receptors: http://www.ncbi.nlm.nih.gov/pubmed/18474100
  29. A 2012 randomized controlled study of laboratory animals with induced chronic arthritis, a the Beijing University of Chinese Medicine, in China, showed that a simple manual or electroacupuncture stimulation to the most commonly used point, ST36, downregulated expression of pro-inflammatory cytokines TNF-alpha and IL-1 beta, and upregulated expression of the anti-inflammatory cytokine IL-2, showing that the treatment is effective in achieving the same goals of corticosteroid medications in the treatment of various arthritic diseases: http://www.ncbi.nlm.nih.gov/pubmed/23140046
  30. A randomized controlled study of laboratory animals in 2009, at the Sino-Japan Friendship Hospital, in Beijing, China, found that electroapuncture stimulation a the points of the spine DU14 and DU4 also induced immune modulation on lymphocyte expression, and downregulation of expression of the key pro-inflammatory cytokine TNF-alpha, and upregulation of expression of the key anti-inflammatory cytokine IL-2 from these lymphocytes, or T cells and B cells. These are the same effects that we see from synthetic corticosteroid medications: http://www.ncbi.nlm.nih.gov/pubmed/19916284
  31. A 2015 randomized controlled study of laboratory animals at the Hubei University of Chines Medicine adnt he Tongji Medical College of Huazhong University, in China, showed that a typical acupuncture treatment with stimulation at the points ST36, GB39, and UB23 produced modulation of the anti-inflammatory pathway of NF-kB in animals with induced Rheumatoid Arthritis. The study used measurements of key cytokines such as TNF-alpha, and measured synovial contents of the affected joints, demonstrating the significant differences between sham and actual acupuncture stimulation, and the differences between the immune effects of diseased animals and healthy controls: http://www.ncbi.nlm.nih.gov/pubmed/26030114
  32. A large 2015 multicenter cohort study in Taiwan found that the use of pediatric Chinese Herbal Formulas and topical herbal extracts reduced the needed exposure to corticosteroid medications in children with eczema (atopic dermatitits), significantly reducing the potential long-term adverse effects: http://www.ncbi.nlm.nih.gov/pubmed/25449448
  33. A 2015 study at the Mount Sinai School of Medicine and the Columbia University Division of Allergy, Immunology and Rheumatology, in New York, U.S.A., showed that a simplified herbal formula provided to pregnant and breast-feeding mothers prevented airway inflammation and modulated pathological immune responses in infants in a laboratory study: http://www.ncbi.nlm.nih.gov/pubmed/25465920
  34. A 2014 study at the Icahn School of Medicine at Mount Sinai, New York, U.S.A. found that a common Chinese Herbal Formula to treat Inflammatory Bowel Disease (IBD - Crohn's Colitis), called FAHF-2 here, based on the classic Wu Mei Wan formula in TCM, exerted significant anti-inflammatory and immunomodulating effects in laboratory animals:http://www.ncbi.nlm.nih.gov/pubmed/24252977
  35. A 2015 study at Fudan University, in Shanghai, China, found that a topical cream containing the herbal chemical baicalin, from the Chinese herb Scutellaria baicalensis, or Huang qin, exerted anti-inflammatory and modulation of keratinocyte growth in the treatment of psoriasis: http://www.ncbi.nlm.nih.gov/pubmed/25932143
  36. A 2015 study at the University of Padova, in Italy, found that the commonly used herbal extract of Boswellia serrata (frankincense tree resin, or Olibanum gum, Ru xiang) provides a host of chemical activities that prevents the gastrointestinal membrane from inflammatory and oxidative damage: http://www.ncbi.nlm.nih.gov/pubmed/25955295
  37. A 2015 study at the University of Tsukuba School of Medicine, in Ibaraki, Japan, found that the Chinese herb Qing dai (Indigo pulverata Levis) attenuated the oxidative damage from NSAID use in the gastrointestinal tract: http://www.ncbi.nlm.nih.gov/pubmed/25678747
  38. A 2015 study of the Chinese herb Epimedii (Yin yang huo) centered on one of its active chemicals, icariin, by the Northwestern Polytechnic University, in Xi'an, China notes that this herbal extract has long been shown to possess potent anti-inflammatory and protective effects on numerous systems in the human organism, as well as osteogenic activity. Such study points to the problems in studying pharmacological effects of herbal extracts, as they contain many chemicals with a diverse array of effects, and studies are presently designed to find evidence of specific chemicals and effects: http://www.ncbi.nlm.nih.gov/pubmed/25634110

"long-term use of high-dose inhaled corticosteroid therapy has potential to cause systemic side effects – impaired growth in children, decreased bone mineral density, skin thinning and bruising, and cataracts. Hypothalamic-pituitiary-adrenal-axis suppression, measured by serum or urine cortisol decrease correlates with the occurrence of systemic side effects of high-dose inhaled corticosteroids."