MANAGEMENT OF COMPLICATIONS OF GLUCOCORTICOID THERAPY

Cortisone was isolated from an extract of the adrenal cortex in 1935 b y Mason and colleagues.(57) Cortisone synthesis was achieved in the mi d-1940s. In 1948, a woman with severe rheumatoid arthritis was the fir st to receive cortisone.(57) By the early 1950s, glucocorticoid prepar ations, both oral and inhaled, had been used to treat patients with as thma. Along with recognition of the beneficial effects of this class o f drugs came an increasing appreciation for their potential systemic s ide effects. In a trial of steroids for chronic asthma published in 19 56, Christie and colleagues(22, 28) reported weight gain, hypertension , and cushingoid facies to be commonly observed side effects. In the e nsuing years, the spectrum of pulmonary diseases for which corticoster oids are used has broadened, and now includes chronic obstructive pulm onary disease (COPD), sarcoidosis, pulmonary fibrosis, and the pulmona ry vasculitides. Additionally, the recent success of lung transplantat ion has created a new population of patients requiring long-term admin istration 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-threaten ing. Indeed, all too commonly, steroid-induced complications may domin ate the clinical course of patients with advanced lung disease. Steroi d-associated complications result from altered cellular function, flui d and electrolyte shifts, modification of normal immune surveillance, and suppression of normal functioning of the adreno-pituitary axis. Th e occurrence of side effects is related, in part, to the method of adm inistration, dose, and duration of use. The appearance of complication s 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individual sensitivities.(25, 68, 129) Finally, some adverse effects become manifest only after the drug is tapered or withdrawn.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 encount ered complications of corticosteroids in the context of the method of delivery, events occurring with chronic use, and events related to ste roid withdrawal.