Diagnosis and treatment: the complications of steroid treatment

WHEN administered in pharmacologic amount, the adrenal glucocorticoids act in an almost magic way to suppress the overt manifestations of a large variety of inflammatory diseases, for which there is no known cause or cure. It is for this nonspecific purpose, rather than for replacement therapy of adrenocortical insufficiency states, that the steroids are so widely used. The extent of their use may be judged from the fact that total manufacturer sales of these products currently exceed $100 million annually. To date, the pharmaceutical houses have synthesized over 1,500 corticosteroid analogues, only a few of which have proved in practice to be superior to cortisol and cortisone as anti-inflammatory agents. The analogues have been created in an attempt to avoid some of the undesirable effects which result from the pharmacologic use of cortisol or cortisone. Table I lists the major metabolic changes produced by the natural steroids and the clinical picture which develops when they are given or secreted in excess. It should be emphasized that the newer steroids avoid only one of these "complications," the action of cortisol given in large doses to cause sodium retention and potassium loss, thus producing edema, hypertension, hypokalemia, and metabolic alkalosis. The avoidance of edema and hypertension has certainly proved desirable in the treatment of nephrosis or rheumatic carditis, conditions for which cortisone is now rarely prescribed. And yet, if given in large enough amount, the analogues, such as prednisone, will produce profound muscular weakness, presumably via this same mechanism. The possible complications listed in Table I ought to warn the physician not to use these steroids to treat trivial ailments.