TR: What should physicians and other health care team members in practice take away from your research? How may it affect patient care or clinical practice?
Dr. Van der Meulen: In general, doctors are aware that glucocorticoids have side effects and are, therefore, careful to prescribe them only to the patients who really need them at the lowest possible dose. This study may raise awareness for the potential psychiatric side effects associated with glucocorticoid use.
TR: Was there anything about your findings that caught you by surprise?
Dr. Van der Meulen: We were surprised by the consistency of the white matter effects and by our finding that we could not only see these effects in systemic glucocorticoid users, but also to a limited extent in inhaled glucocorticoid users.
TR: What are directions for further research?
Dr. Van der Meulen: There are many questions that remain unanswered that we hope to address in the future. For example, how clinically relevant are these effects, and are they reversible? How do they depend on dose and duration of glucocorticoid use and the type of glucocorticoid medication used? And could selective glucocorticoid receptor modulators, a type of glucocorticoid-like medication that has a more selective effect—and therefore potentially has less side effects—prevent these effects from happening?
Conclusion
In summary, Dr. Van der Meulen and colleagues share fascinating new data that both systemic and inhaled glucocorticoids are associated with several brain imaging paraments, and this may contribute to the neuropsychiatric side effects of glucocorticoids. Unfortunately, the p in prednisone still stands for poison. As rheumatologists, we must remain vigilant about limiting glucocorticoid usage when able.
Samantha C. Shapiro, MD, is the executive editor of Harrison’s Principles of Internal Medicine. As a clinician educator, she practices telerheumatology and writes for both medical and lay audiences.
References
- van der Meulen M, Amaya JM, Dekkers OM, et al. Association between use of systemic and inhaled glucocorticoids and changes in brain volume and white matter microstructure: a cross-sectional study using data from the U.K. Biobank. BMJ Open. 2022 Aug 30;12(8):e062446.
- Judd LL, Schettler PJ, Brown ES, et al. Adverse consequences of glucocorticoid medication: Psychological, cognitive, and behavioral effects. Am J Psychiatry. 2014 Oct;171(10):1045–1051.
- Bourdeau I, Bard C, Noël B, et al. Loss of brain volume in endogenous Cushing’s syndrome and its reversibility after correction of hypercortisolism. J Clin Endocrinol Metab. 2002 May;87(5):1949–1954.
- Chen Y, Zhang J, Tan H, et al. Detrimental effects of hypercortisolism on brain structure and related risk factors. Sci Rep. 2020 Jul 29;10(1):12708.
- U.K. Biobank: https://www.ukbiobank.ac.uk/.
- Alexander AL, Lee JE, Lazar M, et al. Diffusion tensor imaging of the brain. Neurotherapeutics. 2007 Jul;4(3):316–329.