An unsatisfactory report card.

The web site http://www.cushings-help.com/ side_effects.htm made for some interesting and challenging reading. The first section reads: ÔSide effects of steroid therapy considered acceptable and expected by the prescriber (though not by the patient!)Õ. That is quite an indictment against us as clinicians, but is it accurate? Regrettably, not only is the statement correct, but as evidenced elsewhere in this issue of the journal (1), the indictment does not go far enough. McDougall et al. (1) report a 10 year retrospective chart review of 512 patients with neuromus-cular disease of whom 209 (41%) received corticosteroids at some point in their management. The diseases being treated varied widely as did the dose and duration of steroid therapy. The average dose 26.6 mg ⁄ day and the average duration of therapy 4.5 years so it is hardly surprising that three out of every four patients receiving steroids experienced one or more adverse effects. About 29% of the patients experienced cosmetic changes such as acne or hirsutism, and 29% had an increase appetite and weight gain – effects that are allegedly considered acceptable and expected by the pre-scriber but not the patient. One might include psychological changes (21%) in this category. To a certain extent this is excusable since there is little that can be offered either prophylactically or even therapeutically for these side effects. Fewer patients had diabetes (12%) but checking for this life changing complication on an annual basis was only done in 38% of the patients. Guidelines for osteoporosis prophylaxis clearly state that this should be considered in all patients receiving steroids for 3 months or longer. Three quarters of the patients were on steroids for >6 months yet osteoporosis prophylaxis was only considered in about half of the patients. Another specialty where use of steroids is common and appropriate is Rheumatology but there too attention to the adverse effects of chronic steroid therapy is apparently sub-optimal (2). About 60% of patients with rheumatoid arthritis were considered long-term users receiving ‡5 mg ⁄ day for ‡6 months. Of these only 37% received baseline bone density scans and in that group bone loss was documented in 70%. Yet only 40% received either prophylaxis or therapy. Failure to appreciate and prevent complications from therapy is not restricted to chronic corticosteroid therapy. In particular adverse but preventable side effects of aromatase inhibitor and androgen deprivation therapies for breast and prostate cancer respectively are often …