Steroids are fast catching up with antibiotics as the most abused class of drugs in your doctor's black bag. There's no doubt that the discovery of steroids a half century ago was a major advance in medicine a life saver for those like the late President John F Kennedy, who suffered from Addison's disease, a disease of the adrenal glands causing insufficient hormone production. Steroids mimic the action of the adrenal glands, the body's most powerful regulator of general metabolism. John Stirling, director of the vitamin company Biocare, credits a very short course (three injections) of steroids with jump starting his failing adrenal system after anaphylactic shock and saving his life.
The problem is, like antibiotics, steroids appear to be a miracle "cure". Patients with crippling arthritis or asthma seem to be instantly better on steroids. The wheeze, the swelling, the pain go away. So doctors turn to steroids as the first, rather than last, line of attack for their anti inflammatory and anti allergic effects.As with antibiotics, what was once reserved for the extreme emergency is now being used on the most trivial of conditions. Steroids are now handed out as readily as antibiotics, even to babies, at the first sign of inflammation of any sort. The latest drug set to replace gripe water for babies with croup is a steroid (budesonide); hydrocortisone is included in the latest over the counter medication for piles. Steroids make up many OTC skin drugs, and are considered the drug of choice for asthma, eczema, arthritis, back problems, bowel problems like ulcerative colitis indeed, for any and all inflammations or allergic reactions and new uses are still being invented. The sole exception is Addison's Disease, where steroids act as a replacement therapy of cortisone, much as insulin is given to diabetics.
Far from being a wonder drug "cure all", steroids cannot cure one single condition. All they do is suppress your body's ability to express a normal response. In a few instances, this type of suppression will give the body a chance to heal itself. But more often, the effect is immediate, devastating and permanent damage. And we are only now realizing just how quickly damage can occur. Despite what doctors say, that steroids only have side effects after many years of use, there is no such thing as a safe dose.
Studies show that steroids cause permanent, debilitating effects after a single dosage. "Steroids are probably the most sleazy of modern day medications," says John Mills, former professor of medicine at the University of California, San Francisco and chief of infectious diseases at San Francisco General Hospital.
Although steroids are used for virtually all types of inflammatory and autoimmune illnesses, they have not been subjected to long term scientific study to find out how or whether they work for specific conditions. Septic shock and adult respiratory distress syndrome are two conditions where steroids were widely used as treatment until scientific trials demonstrated that they were not only of no benefit, but may actually have been doing harm (Science, 1990; 250: 1196-8).
Unlike with antibiotics, steroids are all broad spectrum that is, they don't specify simply the area of the body you wish to treat, but scatter effects through every cell the central nervous system, cells in bone, smooth muscle, blood, liver and a number of other organs of the body (The Lancet, March 9, 1996). Doctors have been trying to rearrange the chemistry of cortisone, to make it more specific to certain parts of the body. However, thus far, this goal has proved elusive; new side effects appear with new preparations and doctors complain that more research is needed into its effects (Europ Resp J Suppl, 1989; 6: 566s-567s).
Doctors have a particular blind spot about these drugs, refusing to believe that steroids can cause the terrible carnage that manufacturers have long admitted to. Recently, a Times column was entitled "Steroids for a Good Start" (June 22, 1995). Another medical column declared: "Any steroid absorbed into the system is rapidly metabolized by the liver, so it has few if any side effects." (Times, March 21, 1996).
But for 30 years we've known that steroids can routinely cause over activity of the adrenal hormones, which produces Cushing's disease, characterized by a fat abdomen and face, and buffalo hump in the back of the neck, high blood pressure and muscle weakness. They can also cause muscle wasting, hyperglycemia, water retention, skin atrophy, bruising and stretch marks, insomnia, serious mood changes, symptoms of schizophrenia or manic depression ("steroid psychosis"), osteoporosis, cataracts or glaucoma, menstrual problems, impotence, loss of libido or even allergic shock, recurrent thrush of the mouth, and diabetes (Physician's Desk Reference).
Side effects common
Gasp, the British Group against Steroid Prescriptions, recently polled its 15,000 members to document just how common these side effects are. In their study, they discovered that at least 70 per cent or more of the group suffered weight gain, bruising, pain (to back and legs) even though steroids are routinely prescribed for back pain muscle weakness and mood swings. Two thirds complained of moon face, headaches, fluid retention, slowness in healing, thinning skin, depression, and headaches. A full half reported they'd developed osteoporosis, and the same percentage, memory loss, headaches, light sensitivity and loss of sex drive. A third complained of buffalo hump, stretch marks and high blood pressure. Almost a quarter had cataracts. Over half the women complained of facial hair growth, and a quarter had period problems. Others complained of psychosis, damage to the immune system, angina and hair loss.
Most significantly, more than half the members had never been warned of these potential side effects. In another survey, of 104 patients, only 63 (or less than two thirds) recalled any advice from their doctor on potential side effects (BMJ, 1996; 312: 542-3).
The most worrying aspect of steroids concerns the possibility that your pituitary gland will stop producing ACTH, a hormone which regulates the adrenal glands, needed by the body during stress and to fight infections. Once you're on steroids, it can be impossible to stop.
Patients on steroids for prolonged periods can turn into steroid "junkies" unable to withdraw from taking the drugs; when the body is flooded with extra cortisone, the adrenal glands decrease their own output sometimes to zero.
Deaths from lack of adrenal gland function have occurred when patients have switched from oral to inhaled steroids without overlapping the drugs. Doctors now know that you must gradually withdraw steroids, so your adrenals will start making cortisone on their own again, but this process is extremely slow; for patients on long term use, it could take up to two years for the body to produce enough adrenal hormone to respond to extra stress from an illness or an accident. Surgeons often give steroids to such patients for operations, but this means that weaning has to begin all over again.
Doctors also like to pretend that if you inhale or rub on steroids, you are less likely to suffer side effects. But new evidence shows that inhaled steroids are not as harmless as medicine previously supposed. The consensus up until now has been that beclomethasone dipropionate (BDP) of 400-800 micrograms daily is appropriate for the three to five year old age group. However, a group of pediatric consultants from various hospitals in Britain showed that this dose was every bit as powerful as 20 times more of the oral variety in suppressing the adrenal and pituitary glands (The Lancet, December 14, 1991). This dosage has also produced significant growth retardation in children.
Steroids in children
The use of steroids in children is difficult to justify. For 30 years, we've known that prolonged use for asthma and eczema retards growth in children (The Lancet, 1966; 2 (463): 569-72) and delays puberty. Many studies of children with juvenile chronic arthiritis given steroids show they suffer growth retardation (Clin & Exp Rheum, 1991; 9 Suppl 6: 37-40). Children given topical and inhaled steroids are prone to the same side effects, such as stunted growth and adrenal suppression (The Lancet, December 14, 1991).
One child covered with eczema from head to food from 18 months was treated once a day from age six with a layer of betamethasone ointment over his entire body; by age 13, he was about nine and a half inches smaller than average. Although he experienced some catch up growth once steroids were discontinued, he never recovered what was estimated to be his likely size (J Amer Med Assoc, August 22/29, 1980).
There's also evidence that steroids may affect a child's cogitive performance. In one study, where children on combination steroid drugs were given tests of visual retention association, the performance of children on the drugs were significantly worse than that of a group of nonasthmatics six to eight hours after receiving steroid medication, although the differences disappeared a day or so after the medication was given. Nevertheless, the difference may be constant for those children permanently on the drugs (J Asthma, 1986; 23 (6): 291-6). There's also been an association between steroids taken in pregnancy and autism in the child (J Aut & Dev Dis, 1983; 13 (3): 325-32).
Evidence also suggests that topical and inhaled steroids can cause cataracts and glaucoma, ordinarily only associated with oral steroids (The Lancet, November 20, 1993), as well as steroid psychosis (Ann In Med, October 15, 1988).
Single high doses of steroids are often used with bronchodilators during emergency asthma attacks. However, these single doses don't always work and themselves can cause side effects, particularly in younger children. One study found little difference between a group of children given the steroids plus bronchodilators and those given the latter drug alone (Pediatrics, August 1995). In fact, in one study, the group given prednisone had more use of emergency room services than the controls (Pediatrics, 1995; 96: 224-9).
Doctors have always assumed that patients can only suffer side effects after long term use. However, one major study shows that major permanent damage can occur even after a few months even on low doses. A randomized, double blind, placebo controlled study conducted in the Netherlands showed that prednisone has a major effect on the bone mineral density of the lumbar spine, as measured by a CT scan. Those patients taking only 10 mg of prednisone (prednisolone in the UK) daily suffered a decrease in bone density of a 8.2 per cent after only 20 weeks of using steroids, compared to a similar sized group taking a placebo. Once the patients were off the drugs, their bone density increased somewhat by 5.3 per cent but not to pretreatment levels. The researchers, who termed this bone loss "quite remarkable", described it as comparable to that suffered by women who'd undergone an operation removing the ovaries or patients who'd been immobilized for extended periods.
The level of bone loss was similar to that reported at much higher doses of the drugs, which suggests that when it comes to dosage, more is not necessarily any more dangerous than less. The Dutch researchers from the University Hospital in Nijmegen concluded that "the use of prednisone should be limited as much as possible to short periods of time, until randomized, controlled trials have shown the efficacy and safety of long term low dose use" with rheumatoid arthritis (Ann Int Med, November 15, 1993).
This study was particularly significant because prednisone is often used in low doses to treat rheumatoid arthritis and even sciatica (pain in the leg originating from the lower back.) Even low doses of inhaled beclomethasone have also been shown to reduce bone formation (The Lancet, July 6, 1991).
Bone mineral density has also been found to be lower with children, the longer they stay on steroids (Pediatric Nephr, 1994, 8(6): 667-70). And even inhaled drugs for such diseases as asthma are found to have adverse effects on bone metabolism and adrenal function at higher dosages (more than 1000 micrograms per day) (Clinical Pharma, 1993; 25 (2): 126-35). Some researchers have gone to the extreme of recommending that patients inhale calcitonin (which slow bone loss in osteoporosis) as a preventive medicine to stop the bone destroying effects of steroids (Arz-Forsch, 1990; 40 (9): 1000-3).
Steroids can even cause death of the mass of bone (osteonecrosis), necessitating joint replacement (Arthro, 1985; 1 (1): 68-72). And although osteoporosis is always linked with women, one study found that bone formation is reduced more in men than women before the menopause (Br J Rheuma, 1991; 30 (2); 86-90).
Besides weakening your bones, steroids can also weaken your muscles. In short courses of high dose, steroids can cause a general atropy of muscles, including those of the respiratory system. After chronic use of moderate doses, patients can suffer a gradual weakness in the muscles of the limbs, reduced respiratory muscle force and even functional alterations in the diaphragm (Euro Respir J, 1992; 5 (8): 997-1003). In another study, more than 80 per cent of patients with bronchial asthma undergoing continuous steroid therapy complained of muscle weakness, which was confirmed on testing (Pol Tygo Lekar, 1989; 44 (27): 632-4).
Even with the so called dramatic effects on such crippling conditions as rheumatoid arthritis, new research demonstrates that these anti inflammatory effects appear to wear off in time, leaving you worse off than you were before. Patients at the Royal University Hospital in Saskatchewan taking prednisone (1 to 23 mg) for an average of 6.9 years had similar rheumatoid arthritis symptoms, such as joint swelling and reduced mobility, after five years, as those who'd never taken the drug. After 10 years, the condition of the group on prednisone was worse than the non drug group, with increased fractures and cataracts (J of Rheumatology, 1994; 21: 1207-13).
Medicine has even identified the syndrome as "steroid resistant asthma" patients who don't respond to normal doses of cortisone where in some cases, the drug makes the asthma worse (Euro Resp J, 1993; 6 (5): 743-7).
Steroids also depress the immune system. Many otherwise benign infections become life threatening. Lexie McConnell, a nine year old living in Oxford, died five weeks after doctors began her on high doses of steroids (80 mg per day) to treat toxoplasmosis in the eye. The drugs suppressed her immune system and therefore made her more susceptible to infections like chickenpox or measles. So concerned were researchers about these effects of steroids that they held off giving them to AIDS patients, lest they only accelerate their disease.
Steroid eye drops
Although it is well known that oral steroids cause glaucoma and cataracts, doctors have used steroid eye drops to treat various diseases causing inflammation including the unspecific "red eye". However, researchers at the Department of Ophthalmology at Royal Liverpool University in Liverpool reported on one 47 year old woman who developed glaucoma and cataracts after using l per cent betamethasone drops and 0.1 per cent dexmethasone drops three times daily over three years. Her GP had given her repeat prescriptions over that time to treat an "uncomfortable" eye later diagnosed as blepharitis, which is best treated by warm flannel compresses, eye baths and, occasionally, a low dose antibiotic. Her treatment was given despite the fact that steroids cause a rise in the pressure in the eye after a few weeks in 40 per cent of people (Inves Ophthalmol Vis Sci, 1965; 4: 187-97). Some studies have suggested that 10-15 prednisone for a year would be sufficient to cause cataract (Dermatol Clin 1992; 10: 505-12). But topical eye drops are just as dangerous; one study showed that one drop of topical steroid a day for one eye would be sufficient to cause cataracts (Survey Ophthalmol, 1986; 31: 260-2).
Neil Rowson, a fellow in oculoplastic surgery at Moorfields at Moorfields Eye Hospital, believes that topical steroids should never be used in general practice for eye disease since GP don't have the tools to measure intraocular pressure, which would predict if a patient is developing glaucoma.
He also says that most common conditions can be managed without referral to a specialist and without steroids (BMJ, September 17, 1994).
The same dangers apply to steroid ointments used for more than two weeks. One case of extensive visual loss was caused by a 1 per cent hydrocortisone ointment available from most pharmacies without a prescription (BMJ, August 20-27, 1994). Even with serious problems like Grave's ophthalmopathy, radiotherapy caused fewer side effects than prednisone (The Lancet, October 16,1993).
Another useless indication for steroids appears to be back pain and sciatica, where effects also wear off in time. For 25 years, patients with back pain have been given steroid injections into the epidural and subarachnoid space. One review of the literature found that there is no consensus on how much should be used and no standard about usage. Good results varied from 20 to 95 per cent, but were found to decrease on long term follow up.
Most damning, when compared with other therapies, steroids were found to have no benefit. The authors of the review concluded that the rationale for using intramuscular or spinal injected steroids "has not been scientifically proven" (Pain, 1985; 22 (1): 33-47).
Steroid injections can also cause infections. In one group of patients with arthritis or bursitis admitted to one of two Danish hospitals, a staphylococcus infection was cultured in all cases. The study found that the incidence of steroid induced infection was 60 times higher than earlier reported. The researchers weren't sure whether the infections had to do with bad hygiene or injecting steroids into cavities with infection (Ugeskrift for Laeger, 1993; 255 (14): 1047-9).
Another area where steroids could be doing more harm than good is for transplants. After a transplant, the patient needs to take drugs to suppress his immune system so that he won't reject the foreign organ. This means the doctor has to perform a delicate balancing act, to keep the organ in place while making sure that the patient survives.
Immunosuppressants like cyclosporine are used, as are steroids. But several studies show that steroids can depress transplant tolerance (Transpl Proceed, Aug 1990; 22 (4): 1989-90). Transplant patients taking steroids also risk cataracts (In J Radia Onc, Bio, Phys, 1995; 32 (3): 661-70) and diabetes (ANNT J, 1982; 9 (2): 66-8). The Harefield Hospital, in Middlesex, which has pioneered transplants, avoids the use of steroids and their rate of complications is much lower.
There is some evidence that steroids cause tumours, particularly of the liver (Environ Health Pers, 1983; 50; 201-8). In one study of young patients of an average age of 31, patients had all developed tumours after six years of use. One third of the patients had a life threatening hemorrhage. These patients were unusual since they were so young and didn't have any other evidence of abnormal cells.