STEROIDS AND HERBS

1. STEROIDS AND HERBS Taken from a lecture given by Ian Breakspear, April 2004

2. Glucocorticoids, also known as corticosteroids, and herbs • These have revolutionised the treatment of severe inflammatory conditions. • They are medicinal agents which are related to hormones produced by the adrenal cortex in response to stress. • There are 3 main endogenous glucocorticoids: a) Cortisol (hydrocortisone) b) Corticosterone c) Cortisone

3. Their pharmacological effects are: • Increase the breakdown of proteins • Increase gluconeogenesis • Stress adaptation • Depression of immune response • Reduce inflammation through • Reduce the number of mast cells • Decrease capillary permeability • Depress phogocytosis

4. The anti-inflammatory effect: They inhibit both early and late stage manifestations of inflammation, due to all types of inflammatory stimuli: • invading pathogens • chemical or physical assault • immune reactions For this reason they are regarded as the most powerful anti-inflammatories, even in severe problems.

5. They decrease: • vasodilation and fluid exudation • action of t-helper cells • accumulation of leukocytes in the area of inflammation • generation and release of oxygen radicals • efficacy of cytokine-activated macrophages • fibroblast function • production of eicosanoids • generation of cytokines • concentration of complement factor • histamine release

6. Clinical uses: • Addison’s disease  replacement therapy • Asthma  inhaled or systemically in severe cases • Severe hypersensitivity reactions  • drugs • insect bites • allergic reactions  both topically and systemically • Prevention of graft rejection

7. Certain neoplastic diseases • Severe inflammatory diseases (especially autoimmune) • Rheumatoid arthritis • SLE • Other connective tissue inflammatory diseases • Crohn’s and ulcerative colitis • Some haemolytic anaemia’s and thrombocytopaenia

8. Adverse reactions: “When they are used as anti-inflammatory agents and immunosuppressive agents, all of their metabolic actions are unwanted side effects” • Decreased bone density due to decreased osteoblast and increased osteoclast activity and alterations in the calcium and potassium balance • Thinning of the skin and easy bruising • Hypertension

9. Decreased healing ability: • Due to decreased collagen and glycolsaminoglycan production from fibroblasts • ‘Catch 22’ in chronic inflammatory diseases • Also means that simple wounds don’t heal well • Tendency to hyperglycaemia can lead to the development of type 1 diabetes

10. Suppressed immune response: • Particularly an increased risk of more severe disease due to acute infection with various opportunistic microbes • Even inhaled steroids can lead to an increased risk of oral thrush • Classic Cushing’s syndrome: • Muscle wasting and negative nitrogen balance • Increased appetite • Obesity (especially abdominal) • Buffalo hump • Moon face with red cheeks

11. Alterations in the stress response: • Often patients exhibit temporary euphoria on higher doses of glucocorticoids • Longer duration of treatment (often coinciding with dosage fluctuations) can result in symptoms such as: depression anxiety tremor insomnia aggression

12. The higher the dose and the longer the use, the greater the risk. • Abrupt cessation or alteration in dosage is very dangerous: • Due to the suppression of endogenous glucocorticoids • Careful and phased withdrawal is necessary if a patient is coming off glucocorticoids, or their dose is being reduced • Recovery of full adrenal function usually takes a minimum of 2 months, sometimes up to 18 months

13. Applying “steroidal” herbs clinically • Used as anti-inflammatories in various inflammatory disorders, particularly: • Hypersensitivity disorders • Autoimmune inflammatory diseases e.g. • SLE • Rheumatoid arthritis • Use with immunomodulators • Inflammation due to infectious diseases e.g. • Hepatitis viruses • EBV, CMV • Upper and lower respiratory infections

14. Asthma • Less useful in diseases such as: • Osteoarthritis • Gout • Overuse injuries • Assist in the recovery of adrenal function after the cessation of glucocorticoid drugs. maintain use for as long as necessary and use either to assist in controlling inflammation, or in helping to re-establish proper adrenal function.

15. Glycyrrhiza Glabra Primary actions: • Anti-inflammatory • Adrenal tonic/adaptogen • Expectorant • Gastro-protective • Hepatoprotective (mild) • Antiviral (mild and mostly local)

16. Pharmacology: • Glycyrrhizin and glycyrrhetinic acid apparently bind to and stimulate steroid receptors. • Also seems to inhibit the breakdown of cortisol • Appears to reduce the adverse effects of glucocorticoid drugs in that it reduces the suppression of healing and reduces the suppression of ACTH secretion and adrenal weight.

17. Clinical uses: • Asthma  with expectorants such as Adhatodavasica and Euphorbia hirta • Acute upper or lower respiratory infections • Viral infections affecting the liver  hepatic viruses, EBV, CMV. • Peptic ulceration • Lethargy and poor stress adaptation

18. Autoimmune inflammatory diseases like rheumatoid arthritis, SLE, connective tissue disorders, Crohn’s and ulcerative colitis. • If requiring a good glucocorticoid-like action, then the best option is the standardised extract, which has much more glycyrrhizin Adverse effects • Aldosterone-like effect resulting in sodium retention, fluid retention and increase in blood pressure

19. Smilax spp. Primary actions: • Anti-inflammatory with particular affinity for the skin • Depurative Pharmacology : • Contains steroidal saponins which have shown anti-inflammatory activity in animal studies Traditional uses: • Psoriasis • Psoriatic arthritis • Venereal diseases

20. Clinical uses: • Mainly for immune mediated skin inflammation. Particularly psoriasis and psoriatic arthritis. • It generally combines with other depuratives and immunomodulators.

21. Bupleurum Falcatum Primary actions: • Used in various forms of liver disease • Hepatic anti-inflammatory • Antitussive • Hepatoprotective • Immunomodulator

22. Pharmacology: • Studies indicate that the main constituents (salkosaponins) increase ACTH levels through a direct effect on the anterior pituitary. This leads to an increase in plasma cortisol. • May also decrease breakdown of cortisol. • Salkosaponins also seem to exhibit direct anti-inflammatory effect. • Improves various aspects of immunity.

23. Clinical uses: • Hepatic inflammation and infection induced hepatitis and autoimmune hepatitis. • Autoimmune renal disease. • Can also be used in autoimmune thrombocytopenia combined with Astragalus.

24. Rehmannia Glutinosa Primary actions: • Antipyretic • Adrenal trophorestorative • Ant-inflammatory Pharmacology: • Inhibits cortisol breakdown. • Reduces adverse changes to pituitary and adrenal cortex when exogenous glucocorticoids are administered. • Has various positive effects on immune function. • Does not appear to have much effect on the liver.

25. Clinical uses: • Autoimmune inflammatory conditions e.g. • Crohn’s and Ulcerative colitis. • Connective tissue diseases. • SLE. • Rheumatoid arthritis. Adverse effects: • Occasionally causes mild nausea and a ‘heavy’ congested sensation in the lower abdomen.

26. Reducing adverse effects of glucocorticoids: Reducing bone density: • Regular weight-bearing exercise (walking, swimming) within tolerance of the patient. • Supplementation with a good complete calcium supplement. Thinning of skin / easy bruising: • Vitamin C and flavonoids.

27. Suppression of immunity: • Quite often this is the desired therapeutic effect from glucocorticoid drugs. • However, it often contributes to further pathology. Leading to regular or more severe respiratory infections • Often immunomodulator/immune enhancing herbs are also required. Echinacea, Andrographis, Picrorrhiza.

28. Decreased healing ability: • Important because glucocorticoids are used for disorders which actually require the encouragement of healing. • Herbal treatment of these conditions often incorporates medicines which encourage healing. Calendula officinalis is used for inflammatory bowel disease. Glycyrrhizaglabra is used for connective tissue diseases. • Grape seed and Curcuma longa are both anti-inflammatories via other non-glucocorticoid mechanisms. • Also vitamin C and flavonoids.

29. Decreased stress response: • Depression: Use Hypericumperforatum, Melissa officinalis, Lavandula spp. • Anxiety or Insomnia: Use Valerianaofficinalis, Lavandula spp, Humuluslupulus • Adaptogens: Use Eleutherococcussenticosus, Withaniasomnifera

30. Re-establishing proper adrenal function upon withdrawing drugs: • Without assistance, can result in emotional, physical and mental lethargy for months. • Herbs are helpful. Use GlycyrrhizaglabraorRehmanniaglutinosa. Preventing and treating oral thrush from inhaled glucocorticoids: • Rinse mouth. • Echinacea spp, Calendula officinalis, Commiphoramolmol mouth washes

31. Always remember wholistic considerations in the treatment of autoimmune diseases: • ‘Steroidal’ herbs • bitters • nutrients • nervines