Anti-inflammatory: Cortisone vs. Ibuprofen

Question

Just a laymen's medical question!

What is the difference between the anti-inflammatory effectiveness of a cortisone like Prednisone vs. the anti-inflammatory effectiveness of Advil/Ibuprofen?

Answer 1

Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) are anti-inflammatory agents that are different structurally and mechanistically from the anti-inflammatory steroids. NSAIDS act by a competitive and reversible active site inhibition of Cyclooxygenase (COX) enzyme.

The inhibition of COX reduces the local synthesis of Prostaglandins (PGs) that include pro-inflammatory actions among the diverse physiological role for the PGs. The PG family is also associated with fever and the perception of pain that accounts for the antipyretic and analgesic effects of the NSAIDs.

NSAIDs are prostaglandin inhibitors and prevent peripheral nociception by vasoactive substances such as prostaglandins and bradykinins. Most NSAIDs inhibit both COX-1, which produces prostaglandins that are believed to be cytoprotective of the stomach lining, and COX-2, which produces prostaglandins responsible for pain and inflammation

Given that glucocorticoids (or corticosteroids) modify the expression of so many genes, and that the extent and direction of regulation varies between tissues and even at different times during disease, you will not be surprised to learn that their anti-inflammatory effects are complex.

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Some studies¹ indeed claim steriodal anti inflammatory drugs to be superior than NSAIDs, but strictly speaking it depends on the condition being managed (in that particular study its Rheumatoid arthritis).

Corticosteroid drugs can relieve inflammation, and in high doses they have a dramatic effect on the symptoms of rheumatoid arthritis. They are used only temporarily, however, because of serious adverse effects during long‐term use. The review found that corticosteroids in low doses are very effective. They are more effective than usual anti‐arthritis medications (non‐steroidal anti‐inflammatory drugs, or NSAIDs)

On the other hand, there seeemed to be no significant differences in their efficacy when managing inflammation after uncomplicated cataract surgery ²:

There was moderate-certainty evidence of no difference in mean cell value in the participants receiving an NSAID compared with the participants receiving a corticosteroid (mean difference (MD) -0.60, 95% confidence interval (CI) -2.19 to 0.99), and there was low-certainty evidence that the mean flare value was lower in the group receiving NSAIDs (MD -13.74, 95% CI -21.45 to -6.04).

The major reason why the former are generally frowned upon as the mainstay of managing inflammatory conditions is perhaps their wide range of adverse effects with long term use.

Low-dose glucocorticoid replacement therapy is usually without problems but serious unwanted effects occur with large doses or prolonged administration of glucocorticoids. The major effects are as follows:

The adverse effects of the glucocorticoids include suppression of the pituitary–adrenal axis that requires dose tapering while withdrawing the drug. GI effects are also common adverse effects and may include peptic ulcer, GI hemorrhage, ulcerative esophagitis, and acute pancreatitis. Characteristic effects of glucocorticoids include weight gain, osteoporosis, hyperglycemia, acne, increased susceptibility to infection, and cushingoid “moon face” and “buffalo hump.” Other adverse effects include headache, vertigo, increased intraocular and intracranial pressures, muscle weakness, psychological disturbances, edema, and hypertension.

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Having said that, the general take home points are:

• NSAIDs are the agents of choice for the treatment of rheumatoid arthritis, osteoarthritis, and ankylosing spondylitis.

• NSAIDs may also be used to relieve musculoskeletal pain, headache, and gouty arthritis.

• More specifically, glucocorticoids are useful for the last resort management of severe, disabling arthritis; severe allergic reactions; seasonal allergic rhinitis; bronchial asthma; chronic ulcerative colitis; rheumatic carditis; nephrotic syndrome; collagen vascular disease; cerebral edema; and topically for inflammatory disorders.

References

1. Corticosteroids versus placebo and NSAIDs for rheumatoid arthritis

2. Non-steroidal anti-inflammatory drugs versus corticosteroids for controlling inflammation after uncomplicated cataract surgery.

3. Rang and Dale Pharmacology 8th ed: Drugs affecting major organ systems.