Management of complications of glucocorticoid therapy

Cortisone was isolated from an extract of the adrenal cortex in 1935 by Mason and colleagues.(57) Cortisone synthesis was achieved in the mid-1940s. In 1948, a woman with severe rheumatoid arthritis was the first to receive cortisone.(57) By the early 1950s, glucocorticoid preparations, both oral and inhaled, had been used to treat patients with asthma. Along with recognition of the beneficial effects of this class of drugs came an increasing appreciation for their potential systemic side effects. In a trial of steroids for chronic asthma published in 1956, Christie and colleagues(22, 28) reported weight gain, hypertension, and cushingoid facies to be commonly observed side effects. In the ensuing years, the spectrum of pulmonary diseases for which corticosteroids are used has broadened, and now includes chronic obstructive pulmonary disease (COPD), sarcoidosis, pulmonary fibrosis, and the pulmonary vasculitides. Additionally, the recent success of lung transplantation has created a new population of patients requiring long-term administration of corticosteroids. Unfortunately, even with judicious use, these agents are associated with a number of side effects, some merely a nuisance but others potentially debilitating and even life-threatening. Indeed, all too commonly, steroid-induced complications may dominate the clinical course of patients with advanced lung disease. Steroid-associated complications result from altered cellular function, fluid and electrolyte shifts, modification of normal immune surveillance, and suppression of normal functioning of the adreno-pituitary axis. The occurrence of side effects is related, in part, to the method of administration, dose, and duration of use. The appearance of complications may also be of a variable and unpredictable nature, however, because of idiosyncratic responses and individual sensitivities.(25, 68, 129) Finally, some adverse effects become manifest only after the drug is tapered or withdrawn. This article discusses the more commonly encountered complications of corticosteroids in the context of the method of delivery, events occurring with chronic use, and events related to steroid withdrawal.