Pulmonary diseases Aspiration pneumonia, bronchial asthma, prenatal prevention of infant respiratory distress syndrome, sarcoidosis
Treatment for transplant rejection is a very important application of glucocorticoids. The efficacy of these agents is based on their ability to reduce antigen expression from the grafted tissue, delay revascularization, and interfere with the sensitization of cytotoxic T lymphocytes and the generation of primary antibody-forming cells.
The benefits obtained from glucocorticoids vary considerably. Use of these drugs must be carefully weighed in each patient against their widespread effects. The major undesirable effects of glucocorticoids are the result of their hormonal actions, which lead to the clinical picture of iatrogenic Cushing’s syndrome (see later in text).
When glucocorticoids are used for short periods (<2 weeks), it is unusual to see serious adverse effects even with moderately large doses. However, insomnia, behavioral changes (primarily hypo-mania), and acute peptic ulcers are occasionally observed even after only a few days of treatment. Acute pancreatitis is a rare but serious acute adverse effect of high-dose glucocorticoids.
A. Metabolic Effects
Most patients who are given daily doses of 100 mg of hydrocortisone or more (or the equivalent amount of synthetic steroid) for longer than 2 weeks undergo a series of changes that have been termed iatrogenic Cushing’s syndrome. The rate of development is a function of the dosage and the genetic background of the patient. In the face, rounding, puffiness, fat deposition, and plethora usually appear (moon facies). Similarly, fat tends to be redistributed from the extremities to the trunk, the back of the neck, and the supraclavicular fossae. There is an increased growth of fine hair over the face, thighs and trunk. Steroid-induced punctate acne may appear, and insomnia and increased appetite are noted. In the treatment of dangerous or disabling disorders, these changes may not require cessation of therapy. However, the underlying metabolic changes accompanying them can be very serious by the time they become obvious. The continuing breakdown of protein and diversion of amino acids to glucose production increase the need for insulin and over time result in weight gain; visceral fat deposition; myopathy and muscle wasting; thinning of the skin, with striae and bruising; hyperglycemia; and eventually osteoporosis, diabetes, and aseptic necrosis of the hip. Wound healing is also impaired under these circumstances. When diabetes occurs, it is treated with diet and insulin. These patients are often resistant to insulin but rarely develop ketoacidosis. In general, patients treated with corticosteroids should be on high-protein and potassium-enriched diets.
B. Other Complications
Other serious adverse effects of glucocorticoids include peptic ulcers and their consequences. The clinical findings associated with certain disorders, particularly bacterial and mycotic infections, may be masked by the corticosteroids, and patients must be carefully monitored to avoid serious mishap when large doses are used. Severe myopathy is more frequent in patients treated with long-acting glucocorticoids. The administration of such compounds has been associated with nausea, dizziness, and weight loss in some patients. These effects are treated by changing drugs, reducing dosage, and increasing potassium and protein intake.