Uses, adverse effects of abuse of corticosteroids. Part I

While no one seems to doubt the importance of corticosteroids as potent anti-inflammatory and immunomodular agents, view about the dreaded complications are also rampant. There appears to be a wide variation in their use among various physicians depending on their individual beliefs, but generally there is a consensus in regard to their use in certain autoimmune/connective tissue disorders such as SLE, various vasculitides, etc., where no acceptable alternative medications exist. In these conditions relatively high doses of corticosteroids are needed until the disease activity is controlled and thereafter attempts should be made to taper down the dose to the lowest possible maintenance dose. In some situations such an attempt may not be successful because of exacerbation in disease activity. In such cases supplemental steroid sparing agents such as azathioprine and others should be considered. Other measures such as alternate day therapy should be considered if shown to be affective in controlling disease activity. Alternate day therapy has been shown to be associated with fewer side effects, notably HPA axis suppression, incidence of infection, myopathy and glucose intolerance. Pulsed i.v. Solumedrol has also been shown to be effective in certain situations such as rapidly progressive glomerulonephritis and renal transplant rejection. Steroids should not be used when an equally effective alternative medication is available such as NSAIDS and disease modifying agents in various inflammatory arthritis. Much of reported side effects in the literature are based on case reports and uncontrolled studies and there appears to be considerable individual variation in susceptibility. Some of the side effects are expected regardless of the size of the dose and cumulative dose whereas others are related to the dose. Certain side effects of steroids use, notably osteoporosis, have been shown to be significantly associated with long term use of corticosteroids whereas in others such as peptic ulcer disease, the association is tenuous with other variables playing a significant role. Potential for abuse/misuse also exists both by the physicians and patients. This, however, is relatively small here in the U.S. compared to developing countries where corticosteroids have been used irrationally and inappropriately in a wide variety of conditions, in high dosages.