Your Lungs on Steroids

When we say something is “on steroids”, we usually mean that it is super-powered, because testosterone and other anabolic hormones promote strength: they stimulate the growth of tissues.

The steroids used in medications, such as those used to treat illnesses in the lungs, are different. These are synthetic glucocorticoids, copy-cats of steroids the body makes, and used for their anti-inflammatory and immune-suppressing capabilities. They are catabolic steroids that trigger the breakdown of peripheral muscle. They are used to quieten an over-active tissue response that is making breathing difficult, such as in asthma.

The tiny pockets in the lungs where the oxygen transfers from your in-

breath to your bloodstream are called alveoli. You can imagine them like

little bunches of grapes at the ends of the lung’s air-passages. Because

they are packed into the lungs so efficiently, if they swell with inflammation they don’t have as much space inside them for that oxygen exchange to happen. And they can’t swell outward as their inflamed neighbours are taking up that space! Steroids calm that inflammation so oxygen transfer is improved. Anyone who has experienced extreme difficulty breathing knows how terrifying that is, and how welcome more oxygen is! At these times steroids can be life-saving.

Sometimes steroids taken short term dampen an inflammatory flare of the immune system, and when the steroid treatments are tapered off, the

problem doesn’t return. But frequently the inflammation they are

suppressing is being driven by another problem in the body, so when the

steroids are tapered, the symptoms return. People who experience this

may be told to take steroids ongoing, to keep the inflammation at a level

where it doesn’t cause symptoms that impair their daily function. Steroid-

containing puffers are the main treatment for chronic breathing disorders, including chronic obstructive pulmonary disease (COPD).

However, there are down-sides to their use. Local side effects to the

mouth are relatively common and easy to identify. They vary a bit between the drugs, but can include:

• Hoarse voice -(dysphonia) in 1- 60% (depending on which puffer), which is generally mild and short term (days or weeks)

• Oral thrush/candidiasis - in 3% of users

Systemic side effects for inhaled corticosteroids are, of course, less than from pills taken by mouth, but the lungs do absorb the steroids into the bloodstream, so they can travel around the whole body. If inhaled corticosteroids are used long-term, they can have other effects:

• On the hypothalamo-pituitary-adrenal axis, which regulates your stress response; affecting mood, digestion, energy storage and expenditure. Adrenal insufficiency can result.

• On bone density, contributing to osteoporosis.

• On eyes, creating cataracts (more so in older folk) and increased intra-ocular pressure.

• On skin: triggering bruising, more likely in older adults and with use of higher doses long term.

• On immunity, including increased risk of pneumonia.

• On growth: reducing growth velocity a little. One centimetre reduction in adult height is seen if used longer than 1 year in childhood. And of course, these puffers are commonly used to treat childhood asthma.

Clinicians are recommended to aim for the lowest possible dose to minimise these systemic side effects.

The side-effect profile differs between different steroids. If you are on a

steroid puffer you could check with your pharmacist that the side-effect

profile of yours is one that plays to your strengths, not one that affects your susceptibilities.

The lungs have their own microbiome, which varies from person to person, and is interactive with the gut microbiome. The lung microbiome is different in people with chronic lung diseases than in healthy lungs. In healthy subjects it is a rich, diverse bacterial community. The composition and size of the lung microbiome changes dramatically in different lung diseases, and it has been shown that disease is associated with a loss of bacterial diversity.

Steroids affect the balance of microbes that make up the microbiota, because they affect some bacterial strains more than others. However, they don’t appear to have as broad effect on the microbiome as many antibiotics do.

In our opinion, the best thing someone in these circumstances can do is

work with a natural health care provider. Antioxidants and omega 3s can help the body deal with inflammation, while some natural supplements can be used to control symptoms. Your naturopathic doctor then will look to identify and treat the root cause of the problem, so that puffer use and side-effects can be kept to a minimum.

Remember, not all puffers contain steroids. Ventolin helps open the

airways to improve breathing, but is not a steroid inhaler. However the

majority of inhalers contain steroids. Many contain 3 drugs: a steroid, a

muscle relaxant, and a bronchodilator to cover three different actions.