醫生爸爸愛足球: Steroid is a double-edged sword

2017-05-09

Steroid is a double-edged sword

Steroids save lives but we have to face-up to their side-effects [19].
100+ indications of steroids
Potential side effects of steroids
Several judgement cases of Medical Council HK Disciplinary inquiries about steroids.

History of the development of corticosteroid therapy [1]

The first clinical evidence that an extract of animal adrenocortical tissue could counteract human adrenal failure was demonstrated in 1930.
In 1948 the first patient with rheumatoid arthritis was treated with cortisone and soon thereafter other rheumatologic patients received cortisone or, to stimulate native cortisone production, ACTH.
Between 1954 and 1958 six synthetic steroids were introduced for systemic anti-inflammatory therapy.
By 1960 all of the toxic effects of chronic corticosteroid administration had been described, as well as protocols to withdraw such drugs while minimizing symptoms of cortical insufficiency.

INDICATIONS OF CORTICOSTEROIDS

Steroid is one of the magic drugs because of many useful indications.

Steroids as anti-inflammatory [2]

(Respiratory) Asthma, chronic obstructive pulmonary disease, acute respiratory distress syndrome (SARS), bronchiolitis, bronchopulmonary dysplasia, croup, Interstitial pneumonitis, interstitial lung disease, Idiopathic Pulmonary Fibrosis, Nonspecific Interstitial Pneumonia, Cryptogenic Organizing Pneumonia, sarcoidosis, Radiotherapy induced pneumonitis, Drug induced pneumonitis, Pulmonary Esinophilia, Idiopathic pulmonary hemosiderosis, cystic fibrosis, allergic bronchopulmonary aspergillosis [3].
(GI and liver) Inflammatory bowel disease, Crohn's disease, ulcerative colitis, autoimmune hepatitis, autoimmune cholangitis, autoimmune pancreatitis, alcoholic hepatitis
(Neurology) Head trauma, spinal trauma, Infectious Meningoencephalomyelitis, Granulomatous Meningoencephalomyelitis, Necrotizing Meningoencephalitis, Steroid-Responsive Meningitis–Arteritis, brain tumor, acquired hydrocephalus and peritumoral edema, Hydrocephalus etc [4].
(Nephrology) Idiopathic nephrotic syndrome, Minimal Change Disease, Focal segmental glomerulosclerosis, Idiopathic membranous nephropathy, IgA nephropathy, Antineutrophil cytoplasmic antibodies-associated vasculitis, Lupus nephritis [5].
(Rheumatology) Osteoarthritis, Rheumatoid arthritis, Psoriatic arthritis, Juvenile idiopathic arthritis, Reactive arthritis, Reiter’s syndrome, Gouty arthritis, Pseudogout, Rheumatic fever, Polymyalgia rheumatica, Systemic sclerosis, Dermatomyositis, polymyositis, Systemic lupus erythematosus, Mixed connective tissue disease, Sjogren’s syndrome, Systemic Vasculitides [6].
(Oncology) Cerebral metastases, cerebral edema, carcinomatous meningitis, lymphagitis carcinomatosis, osteoarthropathy, carcinoid syndrome, large bowel obstruction [7].
(Hematology) Leukemia, Lymphoma, myeloma, Immune Thrombocytopenic Purpura, autoimmune hemolytic anaemia.
(Transplantation) Heart, lung, kidney, liver transplantation.

Steroids and anaphylactic/ allergic reaction
Steroids in replacement therapy
Used in chemotherapy for prevension of nausea along with other anti emetic agents [2].

SIDE EFFECTS of CORTICOSTEROIDS

But this magic drug can cause enough mischief if used inappropriately [8].

Over-dosage or prolonged use may exaggerate some of the normal physiological actions of corticosteroids leading to mineralocorticoid and glucocorticoid side effects [9].

[10] http://medcaretips.com/side-effects-of-corticosteroid-therapy/

mnemonic：CUSHINGOID [11]

Cataracts
Ulcers
Skin: striae, thinning, bruising
Hypertension/ Hirsutism/ Hyperglycemia
Infections
Necrosis, avascular necrosis of the femoral head
Glycosuria
Osteoporosis, obesity
Immunosuppression
Diabetes

Common side effects (1 in 10 to 1 in 100) [12]

increased risk of infection
increased appetite, weight gain, metallic taste
heartburn, indigestion or nauesa
increase blood cholesterol level and glucose
skin changes, thin skin
muscle weakness
mood change, change in sleep pattern
fluid retention, leg swelling, high blood pressure

Rare side effects (less than 1 in 100)

Diabetes
osteoporosis
glaucoma, increased risk of cataract
increased risk of stomach ulcers
weakening of hip joints, avascular necrosis of hip
irregular menstrual cycle

Judgement of Medical Council HK disciplinary inquiries about steroids

Doctor C has been guilty of misconduct in a professional respect, by inappropriately or without good medical reason prescribing systemic Dexamethasone to the Patient. The name is removed from the General Register for 3 months [13].

Doctor M has been guilty of misconduct in a professional respect, with name to be removed from the General Register for 3 months and the removal orders be suspended from operation for 24 months, because Doctor M [14]:

prescribed Dexamethasone and/or Diclofenac, and/or prolonged courses of Dexamethasone and/or Diclofenac, to the Patient without proper justification;
failed to inform the Patient of the fact that Dexamethasone contained steroid;
failed to properly and adequately advise the Patient of the possible side effects of Dexamethasone (which contained steroid) and Diclofenac to the Patient before prescribing and dispensing the medication to the Patient;
failed to properly label the medication dispensed to the Patient in that the name of Dexamethasone written on the drug label(s) did not tally with the medication; and
failed to keep proper medical records of the Patient.

Doctor N has been guilty of misconduct in a professional respect, with name be removed from the General Register for 2 months because Doctor N [15]:

prescribed steroid injections to the Patient without advising her on the nature and side-effects of the said injections; and
prescribed steroid injections to the Patient for such a prolonged period without proper justifications.

Doctor L has been guilty of misconduct in a professional respect, with name be removed from the General Register for a period of 9 months, because Doctor L inappropriately prescribed to the Patient in one consultation two types of drug containing steroid, namely Prednisolone 5mg tablets and Dexamethasone 0.5mg tablets [16].

Doctor H has been guilty of misconduct in a professional respect, with name be removed from the General Register for a period of 10 months [17], because Doctor H:

in the period between 2004 and late 2007 gave steroid injections to the Patient without informing her of the nature of the injections and without advising her of the possible risks and side effects of the medication;
in the period between 2004 and late 2007 gave steroid injections to the Patient despite the fact that she had expressly indicated that no medication containing steroid should be prescribed to her.

Doctor C has been guilty of misconduct in a professional respect, with name be removed from the General Register for 1 month and the removal order be suspended for 1 year, because Doctor C prescribed steroid to his patient without explaining to her the nature of steroid drug, indication and possible side effects [18].

GUIDELINES for treatment of chronic hepatitis B