The Use and Abuse of Corticosteroids

The Use and Abuse of Corticosteroids

Corticosteroids sometimes referred to simply as ‘steroids’, form a large groups of drugs with a common chemical structure.  They possess a diverse range of pharmacological and clinical actions.  Steroids with muscle building potential called “anabolic steroids” are sometimes used for wasting diseases, and abused by athletes or other sports persons.  We for the present, are primarily concerned here with corticosteroids used as medicine for different diseases.

Corticosteroids are normally occurring hormones in the body.  There are three types of steroids – mineralo-corticoids, glucocorticoids and the gonadocorticoids (sex hormones).  The gonadocorticoids are produced by the gonads (testes in males and ovaries in females), while the mineralo- and glucocorticoids are produced by adrenal glands located in the abdomen, resting over the two kidneys – therefore they are also called supra-renal glands.  Their production and release is governed by the pituitary gland located in the brain.

Corticosteroids, which are used as medicine, are chemically synthesized.  There is a large number of synthetic corticosteroids manufactured for use as drugs. While individual products have one or the other advantage, the primary actions are common to all the brands.  The mineralo-corticoids influence metabolism of ‘minerals’ i.e. sodium and potassium, while the gluco-corticoids are important in glucose and fat metabolism.

There are extensive indications for the medical use of corticosteroids.  Their use in adrenal deficiency is primarily for replacement therapy.  More commonly, they are used for suppression of immune activity or to control inflammation in a large number of immunological and inflammatory diseases.  In respiratory conditions, they are used in different stages of asthma and other allergies, chronic obstructive lung diseases, sarcoidosis, certain type of interstitial lung diseases, and pulmonary vasculitic disorders.  They are also used in many other medical illnesses – rheumatoid arthritis, polyarteritis nodosa, systemic vasculitides, skin allergies, urticaria, eczema, eye allergies, allergic rhinitis and a number of other common or uncommon diseases.  Steroids are lifesaving in severe anaphylactic shock, acute severe asthma, transplant rejections and diffuse lung haemorrhage (etc.).

There is no other choice when the medical indication for this use is clear and strong.  What is more worrying is their irrational and prolonged use, frequently without the knowledge of the patient.  There is no monitoring of side effects or attempts at their prevention.  It is common in this country for some medical practitioners to use small doses of corticosteroids even when there is no medical indication, to provide ‘magical relief’ to the patient to earn credit.  This is an abuse which must be avoided at all costs.

Corticosteroids, when used for longer periods in an un-regulated fashion, can lead to occurrence of complications such as salt and water accumulation which manifests with swelling of face and feet, hypertension, glucose intolerance or even frank diabetes,.  They also cause osteoporosis and bone- loss predisposing to spontaneous fractures of bones and complications such as collapse of vertebrae or necrosis of hip-joint bones. Fat redistribution results in thinning of limbs (arms and legs), accumulation of fat over the neck and the upper-back. Muscle wasting, abnormal striae over the body (arms and abdomen), acne and petechiae can also occur.  The symptoms of acidity and gastro-esophageal reflux (retrosternal burning, dyspepsia) are common.  There is also an increased frequency of infection, including tuberculosis in such patients.  

It is important to give supplemental calcium and vitamin D to most of the patients receiving corticosteroids.  Regular monitoring is most important which should be done for blood pressure, blood sugar levels, weight gain/ loss, serum calcium and vitamin D levels.

In summary, the corticosteroids use constitutes a double edged sword.  The use, when medically indicated, works like a wonder. Most importantly, the long-term effects need to be carefully assessed. The wisdom lies in the discretion to decide the indication.  This should be done on the basis of available medical evidence, and not on the whims and fancies of an individual practitioner.