Is psychosis reported for prednisolone in a lower dose than previously tolerated?/nA 53-year-old wo

Fråga: Is psychosis reported for prednisolone in a lower dose than previously tolerated?

A 53-year-old woman has been treated with surgery and radiotherapy against a breast cancer. Due to pneumonitis she was treated with prednisolone 40 mg and became psychotic. Two and three years earlier she was treated with prednisolone 60 mg due to inflammatory bowel disease, without any psychiatric side effects.

Sammanfattning: The mechanism by which glucocorticoids produce psychiatric symptoms is multifactorial. In the present case, changes in disease etc may well alter patient pre-disposition for psychiatric side-effects.

Svar: Glucocorticoid therapy causes psychiatric side-effects in many patients. The percentage of patients developing psychiatric symptoms during glucocorticoid therapy has been reported to range from three to 75 percent, with a weighted average of 28 percent (4). Psychiatric side-effects are dose-related, and appear more often in patients receiving prednisolone 40 mg/day or more, or equivalent doses of other corticosteroids. Psychiatric side-effects have also been reported to occur most commonly in women and middle-aged patients (2). However, there are no indications that either a history of psychiatric illness, or a previous reaction to glucocorticoids, increases the risk (5).

The mechanism by which glucocorticoids produce psychiatric symptoms is probably multifactorial, including both direct and indirect effects on the brain. Steroids have a direct effect on certain parts of the brain through glucocorticoid-specific receptors. Indirectly, glucocorticoids may cause psychiatric side effects through neuroactive hormones, such as norepinephrine, serotonin and beta-endorphins (2, 3).

Physiologically, glucocorticoid side-effects are inversely related to serum albumin levels and liver function. A low serum albumin level, leading to an increase in the amount of free unbound steroid and poor liver function with poor steroid degradation may cause a total body increase of active steroid, making the patient more susceptible to side effects (2).

In the present case, altered susceptibility to prednisolone side-effects seems plausible, as the general condition of the patient, as well as the indication for treatment, has changed. However, other causes for psychosis, such as cerebral metastases, should be excluded. 1 Swedis (The Swedish Drug Information System) (cited 2003-11-11) 2 Klein JF. Adverse psychiatric effects of systemic glucocorticoid therapy. Am Fam Physician 1992;46(5):1469-74. 3 Ling MH, Perry PJ, Tsuang MT. Side effects of corticosteroid therapy. Psychiatric aspects. Arch Gen Psychiatry 1981;38;471-7. 4 Rome H, Braceland F. The psychological response to ACTH, cortisone, hydrocortisone and related steroid substances. Am J Psychiatry 1952;108:641-51. 5 Lewis DA, Smith RE. Steroid-induced psychiatric syndromes. A report of 14 cases and a review of the literature. J Affect Disord 1983;5:319-32. 6 Hall RC, Popkin MK, Stickney SK, Gardner ER. Presentation of the steroid psychoses. J Nerv Ment Dis 1979;167:229-36.