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Glucocorticoid Effects On The Immune System - UpToDate
Glucocorticoid Effects On The Immune System - UpToDate
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All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Jul 2020. | This topic last updated: Aug 04, 2020.
INTRODUCTION
The mechanisms of action of glucocorticoids upon the various effector cells of the immune
system, as well as the effect of glucocorticoids on infection risk and vaccination, will be reviewed
here. The effects of glucocorticoids on other specific physiologic systems are presented
separately:
Glucocorticoids diffuse passively across the cellular membrane and bind to the intracellular
glucocorticoid receptor. Binding of the drug to this receptor creates a complex, which then
translocates into the nucleus, where it can interact directly with specific DNA sequences
(glucocorticoid-responsive elements [GREs]) and other transcription factors.
Effects on gene transcription — Binding of the receptor to GREs may result in either enhancement
or suppression of transcription of susceptible downstream genes. The anti-inflammatory effects
of glucocorticoids result from the following:
● Binding to and blocking promoter sites of proinflammatory genes, such as interleukin (IL)-1-
alpha and IL-1-beta [2].
● Inhibition of the synthesis of almost all known inflammatory cytokines. This is primarily
achieved by competing for or blocking the function of transcription factors, such as nuclear
factor-kappa-B (NF-kB) and activator protein-1 (AP-1), which are required for transcription of
proinflammatory mediators [3,5-8]. This may be mediated in part by glucocorticoid-induced
expression of mitogen-activated protein kinase (MAPK) phosphatase 1 and consequent
dephosphorylation of various proteins that participate in intracellular signaling [8]. These
include Jun N-terminal kinase (interfering with production of c-Jun and AP-1), extracellular
signal-related kinase 1 and 2, and p38 MAPK. Glucocorticoids increase the synthesis of I-
kappa-B-alpha, a protein that traps and thereby inactivates NF-kB [3,5].
Noted consequences of the effects of glucocorticoids on gene transcription include the following:
DOSE RANGES
Some immunologic effects of glucocorticoids are dose-dependent, due primarily to variable
affinity of target genomic sites for the complex of glucocorticoid and glucocorticoid receptor.
High-affinity genomic sites may be affected by low levels of glucocorticoids, with additional genes
affected as the concentration of glucocorticoid increases. Administration of high-dose pulse
glucocorticoids may result in nonspecific general disruption of gene transcription. High-dose pulse
glucocorticoids may also have more rapid effects on leukocyte aggregation, possibly as a
consequence of effects on the expression of leukocyte-adhesion molecules and disruption of
calcium flux across membranes [17,18].
Individuals differ in their susceptibility to the therapeutic and adverse effects of glucocorticoids.
The proposed mechanisms responsible for this heterogeneity are reviewed separately. (See
"Mechanisms and clinical implications of glucocorticoid resistance in asthma", section on
'Mechanisms of glucocorticoid resistance'.)
Higher doses — Doses >1 mg/kg per day in children or >40 mg daily in adults can be considered
higher doses for the purpose of immune function. The immunologic effects of higher-dose, short-
term pulse therapy have also been studied. The acute effects of 1 gram of intravenous
methylprednisolone were evaluated in a small study of patients with rheumatoid arthritis who were
given either one or three daily doses of methylprednisolone (1 gram per dose) [19]. Lymphopenia
developed within 2 hours of the dose, peaked at 6 hours, and resolved by 24 hours with both
regimens. Patients were followed for 16 weeks, during which skin test positivity to purified protein
derivative was unaffected, serum immunoglobulin levels were unchanged, and primary antibody
responses to antigens were normal. In vitro, lymphocyte proliferation to mitogens was maximally
suppressed at concentrations of glucocorticoid that would be achieved by the administration of
approximately 1 gram of intravenous methylprednisolone [20].
● Transient minor decreases in monocytes may be observed within one to two hours, often
preceding the increase in neutrophils [23]. (See 'Phagocytes' below.)
● Transient minor reductions in total lymphocytes may also occur acutely, sometimes with more
sustained lymphopenia [24]. However, effects of glucocorticoids on circulating lymphocyte
subsets are variable. (See 'Lymphocytes' below.)
● Glucocorticoids have no immediate direct effects on erythrocyte and platelet counts; however,
sustained use may reverse the anemia and thrombocytosis seen as a consequence of chronic
inflammation.
● Natural killer cells: Total numbers of circulating natural killer (NK) cells are not significantly
altered following glucocorticoid administration. However, in a study examining acute effects
of hydrocortisone administration on lymphocyte subsets, numbers of immature NK cells were
noted to decrease, whereas numbers of mature NK cells increased. Notably, sustained
upregulation of NK cell activation genes, including KIR3DL2, KLRC3, KLRD1, and GPR56, were
observed as early as one hour after hydrocortisone infusion [23,39]. (See "NK cell deficiency
syndromes: Clinical manifestations and diagnosis", section on 'Biology of NK cells'.)
The following studies have examined the impact of short-term systemic glucocorticoids on
immunoglobulin levels:
● The effect of high-dose, short-term therapy was evaluated in a study of 12 patients with
rheumatoid arthritis, who were given either a single dose of methylprednisolone (1 gram) each
morning for four days or 1 gram three times daily for four days [19]. With both doses, mean
serum IgG levels fell by 10 to 20 percent at one week, then normalized by one month, and
remained normal at four months post-treatment. Another study observed similar changes (20
percent decrease in IgG, which was maximal at two to four weeks after high-dose
methylprednisolone) [48]. IgA dropped 17 percent, with maximal changes at six to eight
weeks.
● In a study of 21 children and adults with asthma who required systemic glucocorticoid
therapy for a mean of eight days, 8 received high-dose intravenous methylprednisolone, and
13 received lower doses of oral prednisone. IgG, IgM, IgA, and IgE levels were compared with
a control group of 20 patients (with or without asthma) who did not require glucocorticoids
[43]. Doses ranged from 20 to 250 mg of prednisone (or equivalent) per day. Of the 21
patients who received glucocorticoids, 15 showed a reduction in IgG of 10 to 15 percent,
which was maximal at two to four weeks after the start of therapy. Levels were approaching
normal by eight weeks. IgA changed in a similar manner, and IgM did not change. IgE was
higher in the treated patients throughout the study. Another study of nine patients with
asthma treated with an average dose of 17 mg of prednisone daily for 15 days found a 22
percent decline in IgG levels and a decline in IgA levels, with no change in IgM, similar to the
previous study [41].
The impact of long-term glucocorticoid therapy is less well-studied, but it appears that a subset of
patients on chronic glucocorticoid therapy can become hypogammaglobulinemic [42,49,50].
● In a study of 253 children hospitalized for severe asthma, the mean IgG level of the group was
25 percent lower than normal, a statistically significant difference [50]. The mean IgM level of
the group was 10 percent higher, and the mean IgA level was normal. The lowest IgG levels
were in steroid-dependent patients, with one-third of this subset having levels <2 standard
deviations below the normal mean.
● In a study of 101 unselected adults with asthma of all severities, the mean IgG of the group
was lower than normal, but the difference was not statistically significant [49]. Mean IgA and
IgM levels were not different from normal. Twelve individuals were hypogammaglobulinemic,
with serum IgG <600 mg/dL (range 315 to 595) [49]. These patients did not have more
sinopulmonary infections. Hypogammaglobulinemia was most strongly associated with an
average daily dose of ≥5 mg for at least two years.
Glucocorticoids also inhibit the acute generation of both Th1- and Th2-derived cytokines by
activated T cells, although the inhibitory effect on expression of Th1 cytokines appears to be
greater [61]. Thus, treatment with glucocorticoids may be associated with a shift in the expression
of Th2-derived cytokines relative to Th1 cytokines (table 2) [62,63].
Mast cells and basophils — Glucocorticoids have been shown in vitro to inhibit both production
of cytokines and degranulation by mast cells. The noted inhibition of inflammatory cytokine
production by mast cells appears to occur through suppression of gene transcription as described
for other leukocytes. The inhibition of mast cell degranulation by glucocorticoids has been shown
to be time-dependent, mediated through the upregulation of inhibitory regulators of signaling, such
as src-like adapter protein-1 [69-71].
INFECTION RISK
Systemic glucocorticoid therapy is associated with an immediate increase in the risk of infection,
especially with common bacterial, viral, and fungal pathogens, due to its dose-dependent inhibitory
effects on phagocyte function. In addition to glucocorticoid dose, the intensity of therapy and
several patient-specific factors influence infection risk. In contrast to systemic therapy, inhaled
and topical corticosteroids are usually not implicated in increased risk of systemic infections. The
side effects of inhaled and topical corticosteroids are reviewed elsewhere. (See "Major side
effects of inhaled glucocorticoids" and "Topical corticosteroids: Use and adverse effects", section
on 'Adverse effects'.)
Dose and intensity of therapy — Infection risk is directly related to glucocorticoid dose. The risk
begins to normalize as soon as high-dose therapy is complete. In contrast, the effects on
phagocytic cell function with longer-term, low-dose use are minimal, but there may be some
inhibition of adaptive immune responses with increasing duration of therapy. For these reasons,
glucocorticoid-sparing therapies and alternate-day dosing are advisable when possible.
Patient-specific factors — Patient-specific factors that may influence infection risk include
underlying disease(s), the presence of concomitant immunosuppressive therapies [74,75], and
whether the patient is hospitalized. When used in combination with other immunosuppressive
drugs, as in recipients of solid organ transplants, there is a risk of both newly acquired infections
and reactivation of latent viral infections. These infectious complications are discussed in more
detail elsewhere. (See "Infection in the solid organ transplant recipient".)
Older patients and those with lower functional status are also at higher risk for infection [76]. In
addition, patients taking glucocorticoids may not manifest signs and symptoms of infection as
clearly, due to the inhibition of cytokine release and associated reduction in inflammatory and
febrile responses. This can impair early recognition of infection.
Types of infections — Common viral (mainly herpes viruses), bacterial (Staphylococcus aureus and
others), and fungal (mainly Candida species) pathogens are encountered with greater frequency in
a dose-dependent manner during therapy with glucocorticoids.
● Herpes zoster may occur more commonly among patients taking low-dose glucocorticoids. In
an analysis of >28,000 patients with rheumatoid arthritis, glucocorticoid therapy (prednisone
≥7.5 mg/day) was a significant independent risk factor for development of herpes zoster [77].
The use of zoster vaccines in patients receiving glucocorticoids is discussed separately. (See
"Vaccination for the prevention of shingles (herpes zoster)", section on 'Immunocompromised
hosts'.)
● Other helminthic or protozoan infections are unusual, except in areas of the world where they
are endemic (eg, Plasmodium falciparum). (See "Malaria: Epidemiology, prevention, and
control".)
● Opportunistic infections with organisms of low pathogenicity usually occur only in patients
with very significant immunosuppression, such as those receiving prolonged glucocorticoids
in addition to other immunosuppressant drugs or those with underlying immunosuppressive
conditions (eg, hematologic malignancy). Pneumocystis jirovecii (formerly Pneumocystis
carinii) pneumonia is associated with the use of glucocorticoids, both with chronic use of
moderate doses and short-term use of high doses. Indications for prophylaxis against P.
jirovecii are discussed separately. (See "Treatment and prevention of Pneumocystis
pneumonia in HIV-uninfected patients", section on 'Indications'.)
Magnitude of increased risk — Studies of chronic glucocorticoid therapy (prednisone in most
studies) in patients with rheumatoid arthritis, systemic lupus erythematosus, and other
autoimmune disorders provide some information about the magnitude of the increased risk [77-
80]:
● Similar findings were noted in a study of 223 patients with lupus who were not receiving other
immunosuppressive agents [79]. The risk of infection rose from 1.5-fold at an average
prednisone dose below 10 mg/day to over eightfold in patients receiving doses above 40
mg/day. However, patients receiving higher doses also had more severe underlying disease.
One study suggests that even short-term outpatient glucocorticoid use is associated with an
increased risk of sepsis, although the absolute risk appears to be low. A retrospective cohort study
and self-controlled case series that used a nationwide dataset of private insurance claims in the
United States assessed the risk of sepsis in 327,452 adults aged 18 to 64 years, who received at
least one outpatient prescription for short-term use (<30 days) of oral glucocorticoids over a three-
year period [81]. The median number of days of use was 6 (interquartile range 6 to 12 days), with
47.4 percent receiving treatment for 7 or more days. The most common indications for use were
upper respiratory tract infections, spinal conditions, and allergies. Within 30 days of starting
glucocorticoid therapy, there was an increase in rate of sepsis (incidence rate ratio 5.30; 95% CI
3.80-7.41), which diminished over the subsequent 60 days. The increased risk persisted at
prednisone-equivalent doses of <20 mg/day (incidence rate ratio 4.02). However, the absolute risk
of sepsis in glucocorticoid recipients remained low. For patients who had a clinic visit, the risk of
hospital admission for sepsis during the 5- to 90-day period after the visit was 0.05 percent in
glucocorticoid users compared with 0.02 percent in nonusers.
Measures to reduce risk — There are several strategies to help reduce the risk of infection
associated with glucocorticoid therapy.
Alternate-day dosing — The infection risk may be significantly lessened by the use of short-
acting preparations (such as prednisone) given every other day (table 1) [24]. In one retrospective
report of 70 patients with various inflammatory conditions treated with alternate-day prednisone at
mean doses of 45 to 60 mg daily, none developed serious infections [24]. Strategies to reduce the
side effects of glucocorticoids are reviewed in more detail elsewhere. (See "Pharmacologic use of
glucocorticoids", section on 'Alternate-day administration' and "Pharmacologic use of
glucocorticoids", section on 'Minimizing glucocorticoid side effects'.)
IMPACT ON VACCINATION
A small number of studies have evaluated the ability of patients receiving glucocorticoid therapy
to respond to vaccination. Glucocorticoid dose and duration, as well as the patient's underlying
state of health or disease, impact the response to vaccination.
In patients who do show evidence of impaired vaccine response, removal of chronic, low-dose
glucocorticoid treatment may result in improved antibody production [44].
Higher doses — For the purposes of immune response to vaccines, the Advisory Committee on
Immunization Practices (ACIP) considers doses of prednisone equivalent to ≥2 mg/kg of body
weight or ≥20 mg/day for patients weighing >10 kg, when administered for ≥14 consecutive days
to be thresholds above which vaccine responses may be suppressed [86]. When possible, it is
therefore preferable to wait until the patient has transitioned to lower doses of glucocorticoids or
stopped therapy altogether to administer killed or attenuated vaccines. Live vaccines are
discussed below. (See 'Avoidance of live vaccines' below.)
Live-virus vaccines can be administered to patients (provided there are no other contraindications,
such as severe immunodeficiency) who are receiving glucocorticoid therapy when administration
is [86]:
For patients receiving brief courses of high-dose glucocorticoids (ie, ≥14 days), live-virus
vaccination should be deferred for at least one month after discontinuation [86].
The administration of various vaccines in transplant candidates and recipients, as well as other
special patient populations is reviewed in detail separately.
● Glucocorticoids diffuse across the cell membrane and bind to the intracellular glucocorticoid
receptor to form a complex that translocates into the nucleus. This complex interacts with
DNA, resulting in altered transcription of various glucocorticoid-responsive genes. Post-
translational events are also affected. (See 'General mechanism of action' above.)
● Doses of less than 1 mg/kg per day of prednisone in children or less than 40 mg per day in
adults can be considered low-to-moderate. (See 'Dose ranges' above.)
● Glucocorticoids have profound effects on the cellular functions of leukocytes and endothelial
cells, resulting in reduced ability of leukocytes to adhere to vascular endothelium and exit
from the circulation. Entry to sites of infection and tissue injury is impaired, resulting in
suppression of the inflammatory response. (See 'Leukocyte trafficking' above.)
ACKNOWLEDGMENT
The editorial staff at UpToDate would like to acknowledge E Richard Stiehm, MD, who contributed
as a Section Editor to an earlier version of this topic review.
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Duration of action
Glucocorticoid Adults Children
(hours)
Prednisone 40 mg 1 mg/kg 12 to 36
Prednisolone 40 mg 1 mg/kg 12 to 36
Th1
IL-2
IL-3
IFN-gamma
TNF
Th2
IL-4
IL-5
IL-6
IL-9
IL-10
IL-13
Th17
IL-17
Treg
TGF-beta
IL-10
Th: T helper cell (types 1, 2, and 17); IL: interleukin; IFN: interferon; TNF: tumor necrosis factor; Treg: T regulatory cell; TGF: transforming-
growth factor.
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