General Considerations

Short-term glucocorticoid therapy of life-threatening diseases, such as status asthmaticus, provides dramatic improvement with few complications. However, when administered in pharmacological doses for long periods, steroids generally produce serious toxic effects that are extensions of their pharmacological actions. No route or preparation is free from the diverse side effects (Table 60.2), although individuals receiving comparable doses of glucocorticoids exhibit variations in side effects.

Glucocorticoids are cautiously employed in various disease states, such as rheumatoid arthritis, although they still should be regarded as adjunctive rather than primary treatment in the overall management scheme. The toxic effects of steroids are severe enough that a number of factors must be considered when their prolonged use is contemplated.

The first point is that treatment with steroids is generally palliative rather than curative, and only in a very few diseases, such as leukemia and nephrotic syndrome, do corticosteroids alter prognosis. One must also consider which is worse, the disease to be treated or possible induced hypercortisolism. The patient's age can be an important factor, since such adverse effects as hypertension are more apt to occur in old and infirm individuals, especially in those with underlying cardiovascular disease. Glucocorticoids should be used with caution during pregnancy. If steroids are to be employed, pred-nisone or prednisolone should be used, since they cross the placenta poorly.

Once steroid therapy is decided upon, the lowest possible dose that can provide the desired therapeutic effect should be employed. Relationships of dosage, duration, and host responses are essential elements in determining adverse effects. Increasing attention is being given to the use of lower doses of glucocorticoids in combination with other drugs that can have a synergis-tic effect on a given disease. Moreover, the lowered dose levels of steroid will minimize the side effects.

L TABLE 6C.2 Complications of

Glucocorticoid Therapy

Hematological and immuno

Central nervous system

logical

Insomnia

Leukocytosis

Depression

Lymphopenia

Nervousness

Eosinopenia

Psychosis

Altered inflammatory

Fluid and electrolyte

response

Na+ retention

Gastrointestinal

K+ loss

Peptic ulceration

Negative Ca++ balance

Fatty liver

Hypertension

Pancreatitis

Endocrinological

Nausea, vomiting

Suppression of HPA axis"

Metabolic

Antagonisms with insulin,

Hyperglycemia

parathyroid, thyroid

Protein wasting

Skin

Hyperlipidemia

Thinning of skin

Obesity

Striae purpurae

Musculoskeletal

Ecchymoses

Myopathy

Acne

Growth failure

Hirsutism

Osteopenia

General

Ocular

Cushingoid features

Posterior subcapsular

Truncal obesity

cataracts

Withdrawal syndrome

Increased intraocular pressure

"Hypothalamic-pituitary-adrenocortical axis.

Increased intraocular pressure

"Hypothalamic-pituitary-adrenocortical axis.

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