Cleveland Clinic Journal of MedicineCorticosteroids: Giving and Taking Away

Corticosteroid Dilemma: Balancing Efficacy and Adverse Effects in Chronic Treatment

The editorial by Brian F. Mandell, MD, PhD, featured in the Cleveland Clinic Journal of Medicine, discusses the complex dual nature of corticosteroid use in clinical practice. Highlighting both the transformative effects and the potential for significant adverse outcomes, the piece draws on recent studies and longstanding clinical observations to discuss optimal strategies for managing corticosteroid therapy. This summary aims to distill key insights for physicians navigating the intricacies of prescribing these potent drugs.

Key Points:

• Therapeutic Paradox: Corticosteroids are described as both highly beneficial and potentially harmful, capable of rapidly improving patient mobility and function, yet also leading to serious side effects with long-term use.
• Selected Studies: Two articles in the journal issue focus on contrasting aspects of corticosteroid use: their role in managing active infections like Pneumocystis jirovecii pneumonia and the challenges of glucocorticoid withdrawal syndromes.
• Accepted Practices: Use of corticosteroids in treating severe infections such as bacterial meningitis and severe PJP in certain patients is now a reasonably accepted practice, despite ongoing concerns about dosage and specific corticosteroid types.
• Risk of Infections: The use of mid- to high-dose corticosteroids increases susceptibility to infections, requiring careful patient monitoring.
• Long-term Management: Recent clinical trials have prompted a reevaluation of the approach to long-term corticosteroid use, advocating for minimal usage to avoid systemic side effects.
• Withdrawal Challenges: The process of tapering off corticosteroids involves complex clinical scenarios, including potential adrenal insufficiency and various withdrawal syndromes that often coexist.
• Clinical Observations by Dixon and Christy (1980): The classic study outlined distinct withdrawal syndromes, such as symptomatic adrenal insufficiency and dependency on steroids, contributing to the understanding of patient responses to steroid tapering.
• Practical Implications for Treatment: Physicians are cautioned against the overuse of steroids by patients, especially as dose reduction might worsen their condition without proper management strategies.

“In Dickensian terms, corticosteroids are the best of drugs and the worst of drugs. As I often tell patients, we will both love them and hate them.”
– Brian F. Mandell, MD, PhD

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