Systemic corticosteroid therapy—side effects and their management
Corticosteroids have been used in ophthalmology for almost 50 years. Hench, in 1949,1 was the first to report on the beneficial effects of ACTH and cortisone. His work was with rheumatoid arthritis and since 1929 he had noticed that rheumatoid arthritis improved in pregnancy and jaundice. He conjectured that an adrenal hormone might be the common agent causing this improvement. In 1948 he managed to acquire the necessary hormones and found clinical improvement in the rheumatoid arthritis and a reduction of the erythrocyte sedimentation rate on treatment with the hormones and relapse when they were stopped. His article concluded that theoretically these agents may be of benefit in other conditions which can be relieved by pregnancy and jaundice. Very soon after this steroids were used, both systemically and topically, to treat inflammation of the eye.
Within ophthalmology there are many indications for the use of corticosteroids. The decision to institute steroid therapy always requires careful consideration of the relative risks and benefits in each patient. In uveitis, for example, the use of corticosteroids may often be in high doses for long periods of time.2 Before starting systemic steroids the ophthalmologist must consider:
the reasons for initiating steroid treatment
the expected visual outcome
how the patient will be assessed
the impact on any associated systemic disease.
If a beneficial effect is not seen within the expected time scale the corticosteroids should be reduced and stopped.
This review considers some of the non-ocular problems and dilemmas encountered when systemic steroids are used, with practical suggestions to minimise their side effects. In particular, the new recommendations by the Department of Health on the indications for intervention following exposure to chickenpox or shingles will be discussed and recent publications on the management of corticosteroid osteoporosis will be reviewed.
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