Systemic Side Effects and Complications

The effectiveness of corticosteroids does not come without a price. Corticosteroids mimic substances within our bodies, substances that have many actions in addition to reducing inflammation. Corticosteroids may accentuate or alter these other actions, resulting in many potential risks and side effects. As with most therapeutic drugs, the majority of side effects are more pronounced with systemic therapy, though they may follow all routes of administration. Punctal occlusion is advised with topical ocular corticosteroids to reduce potential complications.

Systemically, the use of these drugs may result in fat redistribution, muscle and bone weakness, fluid and electrolyte imbalances, growth retardation, stomach ulcers, and various psychoses. In addition, patients undergoing corticosteroid therapy become much more susceptible to a new or relapsing infection. This is especially true of herpetic infections. The reason is simply that the body's immune response is decreased during therapy. As a result, the body cannot mount a substantial defense against its attackers, and infections become more likely. Wound healing may also be delayed. Therefore, corticosteroids must be used cautiously in patients with active infection, a history of recurrent infection, or a decreased immune system.

Another major concern with the use of corticosteroids is adrenocortical insufficiency. The adrenal gland is an endocrine (hormone-producing) gland located on top of each kidney. The adrenal cortex produces corticosteroidlike chemicals. In adrenocortical insufficiency, there is a decrease or shutdown in the body's natural production of similar substances. Due to physiologic biofeedback, when corticosteroid therapy is used, the body senses the additional drug in the system. The body then decreases natural production in order to bring levels back into balance. When natural production is diminished over time, there may be atrophy (tissue death) of the adrenal cortex. If atrophy occurs, the body can no longer make the normal quantity of chemical itself, causing problems when the therapeutic dose is discontinued.

Adrenocortical insufficiency is usually temporary but can be permanent and is directly related to high doses and lengthy therapy. Adrenal suppression may be so severe that physiologic production cannot begin quickly enough when extended therapy is discontinued. Once withdrawal of the exogenous source has occurred, the required levels for normal body functions cannot be maintained. This can be a very dangerous situation. First, with inadequate levels of corticos-teroids (physiologic or therapeutic), inflammation cannot be suppressed, and a rebound of the condition can occur. New organisms may also take advantage of the body's weakened state, and secondary problems can arise. Lastly, "steroid withdrawal" may cause symptoms of lethargy, weight loss, headache, fever, muscle soreness, nausea, and vomiting.

Because of the risks of stopping treatment prematurely, systemically administered corticosteroids should not be discontinued abruptly if the length of therapy exceeds 5 to 7 days. Instead, therapy should be tapered by slowly reducing the dosage and frequency of administration. This allows physiologic levels to recover, thereby avoiding unwanted complications. The rate of withdrawal must correspond to the length and degree of therapy; the longer the course of treatment, the slower the withdrawal of the medication.

Suppression of adrenocortical function can occur but is rare with use of topical drops, and it is even less common with ointments and creams. Suppression is not expected after short-term topical therapy.

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