The Discovery of Corticosteroids: From Euphoria to Pessimism

Category: Medications & Supplementation Published on Wednesday, 25 June 2008 Written by Yong Tsai, MD

Are corticosteroids a miracle drug or was their discovery a curse? Let’s take a look back in time and see.

Chronic and progressive inflammatory arthritis and autoimmune diseases have been around for many years. Countless people have suffered damage to bones, joints and ligaments due to persistent inflammation caused by an imbalance of immune system (autoimmunity) and a result of diseases such as rheumatoid arthritis and osteoarthritis.

By the late 1940s, it became clear that in order to bring autoimmune diseases under good control, it was necessary to suppress inflammation and the immune system. In 1948, E. C. Kendall and P.S. Hench discovered a compound that was miraculously able to suppress inflammation, and reverse the symptoms of rheumatoid arthritis. The active component they discovered was a form of corticosteroids.

It all began in September 1948, when a middle- aged woman with rheumatoid arthritis (RA), experiencing severe pain and joint swelling, was first experimentally given a series of corticosteroid injections over a course of a few weeks. After the trial period, the woman’s symptoms had disappeared and she got up and walked away from the bed in which she had been confined to for several years. This startling result stunned people throughout the world, and in 1950, P. S. Hench and E. C. Kendall were awarded the Nobel Prize in Physiology and Medicine. It seemed a cure for arthritis had been discovered: corticosteroids.

Most inflammatory arthritis and autoimmune diseases were responsive to corticosteroids if they were given in an amount sufficient enough to cease the inflammation. Because of this immediate and powerful effect, it was considered a miracle drug. Since then, corticosteroids have been widely used to treat different diseases and many lives have been saved due to their powerful anti-inflammatory effect.

However, over the years, unpleasant side effects caused by corticosteroids emerged and became worrisome. The most common side effects were weight gain, high blood pressure, thinning of the bones, increased risk of becoming diabetic, increased risk of contracting an infection, poor sleep, cataracts, glaucoma, and abdominal stretch marks. Generally noted, the higher the dose of steroids and the longer they were prescribed, the greater the risk of side effects.

Because of this, the medical pendulum swung in the opposite direction, from extreme euphoria to extreme pessimism. Patients were warned of the hazards of these drugs, and their use became restricted. Some patients became so frightened of the side effects associated with corticosteroids they even declined treatment.

In order to better understand another side effect of corticosteroids called “adrenal insufficiency”, it is necessary to explain the function of the adrenal glands. The adrenal glands can increase their production of cortisol, a natural hormone which it produces mostly in the morning, to five times the normal level to help the body cope effectively with additional stresses, such as infection, trauma and surgery. Cortisol is an anti-inflammatory substance that the body uses to decrease the number of white blood cells and to extract the secretion of inflammatory chemicals from tissue. Since the normal production of cortisol is suppressed after extended use of corticosteroids, the adrenal glands may not produce enough cortisol to meet your body’s demands during a period of stress. This is called “adrenal insufficiency” or “crisis”, which can be life threatening. Therefore, when corticosteroid dosages are reduced or eliminated, they must be decreased gradually to allow the body’s own adrenal glands to resume their natural production of cortisol.

Cortisol’s synthetic counterpart, “Prednisone”, is four to five times more potent. A 5mg to 7.5mg dose of Prednisone provides the equivalent of the body’s natural daily output of cortisol. Sometimes, long-term low-dose Prednisone (5mg to 7.5mg) therapy is appropriate for patients undergoing treatment for rheumatoid arthritis. During acute flare-ups, patients occasionally require a higher dose of Prednisone for a short period of time, which is decreased to the lowest effective dose or discontinued, if possible. Another instance in which high doses are utilized is for severe inflammation in the heart, lungs, eyes and blood vessels. However, intra-articular corticosteroid injections (cortisone injections directly into a joint) are an alternative to systemic (whole body) treatment when only one or two joints are affected.

Even though corticosteroids work remarkably well as an anti-inflammatory and immunosuppressive drug, there is no conclusive evidence that they are able to change or modify the course of certain diseases such as rheumatoid arthritis. Corticosteroids cannot solely take on the responsibility in treating patients with rheumatoid arthritis because they can only provide symptom relief. Corticosteroids must work hand in hand, in this case, with disease modifying anti-rheumatic drugs (DMARDs) to stop the progression of inflammation and joint destruction. Together, these drugs can stop joint deformity before it begins.

So, back to our initial question: Are corticosteroids a miracle drug or do they just cause more problems than they solve? The answer lies in how properly they are used. And due to their powerful anti-inflammatory effects, corticosteroids will always play an important role in managing inflammatory arthritis and autoimmune disease.

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