The risks of local and systemic corticosteroid administration

Abstract

The pattern of use of corticosteroid therapy differs widely in rheumatology. The prevalence of steroid use in rheumatoid arthritis, for example, may vary markedly in different countries. Within Britain, beliefs about the uses of corticosteroid therapy are strongly held by rheumatologists, yet show wide variation (Byron and Mowat, 1985). Our knowledge about the efficacy and risk of corticosteroid administration remains in large part suboptimal. As might be expected with any group of drugs that exert a wide range of pharmacological actions and are routinely used in a variety of pathological conditions, reports of adverse effects of corticosteroids are frequent. However, much literature on the subject is derived from case reports and uncontrolled studies. In the case of several potential adverse effects, careful review of the evidence leads to the conclusion that the risk of their occurrence, if present at all, is small. The purpose of this review is to consider these adverse effects in relation to the three common routes of administration: oral, intravenous pulse and intrasynovial. Corticosteroids are among the most effective agents currently available for the alleviation of symptoms attributable to inflammatory arthritis. The discovery of some of these effects by Hench at the Mayo Clinic over forty years ago (Hench, 1952) was rapidly followed by the widespread use of corticosteroids in rheumatoid arthritis. The optimism that cortisone might be a cure for the condition quickly evaporated as some of the toxic effects of systemic corticosteroid therapy came to light over the ensuing decades. There followed a backlash as the more serious of these effects, particularly at the high doses being used, were set against a failure of steroid therapy to alter longer term progression of rheumatoid arthritis. The tone of much subsequent debate on the balance of risks and benefits of corticosteroid therapy has been clouded by the emotional arguments of these earlier years.