Musings of a Dinosaur

A Family Doctor in solo private practice; I may be going the way of the dinosaur, but I'm not dead yet.

Wednesday, February 28, 2007


Corticosteroids, or glucocorticoids, are synthetic versions of the body's naturally occuring stress hormone, cortisol. When used for medical therapeutics, they are the ultimate two-edged sword.

When I was in residency (20 years ago) we had a patient who was a textbook case of just about every steroid-induced complication there is. His underlying disease was pemphigus vulgaris, a nasty autoimmune blistering disease of the skin. In those early days of immunomodulation, the only medication that worked for him was prednisone. But the many years he had been on it (at varying but usually fairly high doses) had left him diabetic, hypertensive, osteoporotic, buffalo-humped, weak, and with purple striae, central obesity and peripheral muscle wasting, acne and cataracts. He was a mess.

On the other hand, the classic steroid-responsive disease is something called polymylagia rheumatica, which I actually diagnosed and treated a few months back. Literally overnight, an elderly gentleman with debillitating pain and weakness in his thighs and upper arms felt almost 100% better. I'll be carefully weaning him down off his prednisone over the next year or so. Hopefully he won't end up like my patient in residency.

Steroids are basically the most powerful anti-inflammatories we have. (Hence the general term for all the lesser ones as "non-steroidal.") They don't work instantly, in a matter of minutes or hours, because the drug has to be taken up by the body's cells and then transported into the cell nucleus, where it does its anti-inflammatory magic at the nucleic acid level.

All this by way of introduction:

Still so hoarse as to be essentially incapacitated after 5 days, I -- gasp -- went to a doctor. An ENT friend who scoped my throat (NOT fun; nostrils are my least favorite orifice to have messed with) and was underwhelmed. But he did suggest that a short steroid course would help me feel better faster. At that point, I was sufficiently miserable that I decided what the hell, why not do something totally out of character and try compliance with medical advice. So that night I took 60 mg of prednisone, as directed.

Prednisone pills are bitter and kind of hard to swallow, and I have trouble swallowing pills in the first place. I took them after dinner, as one of the side effects -- GI upset -- can be mediated that way. I've been told by my endocrine consultants that the best way to avoid problems with the body cutting back on its own production of cortisol ("why bother when there's plenty of prednisone around" is how the adrenal gland sees it; the problem is when the prednisone is stopped and the adrenal can't pick up the sudden slack fast enough) is to take steroids as a single daily dose in the morning. Because of the delay in action, I usually tell my patients to go ahead and take the first dose with their next meal, and begin the morning dosing the following day; that's what I did.

I am thrilled to report that I am at least 95% better. I was probably on the mend anyway, as my voice might have been marginally better yesterday, but I think the steroids were probably the difference between what I would have guessed about a 50% improvement (my guesstimate if I hadn't taken anything) and how I feel. I'm sure the good night's sleep I finally got played a huge role. But I am virtually certain that I am reaping the benefits of my steroid "blast" (what I call a three day course of 60 mg of prednisone.)

Thank goodness for modern medicine. I'm just glad I'm on the right edge of that sword.


At Wed Feb 28, 11:07:00 AM, Anonymous Anonymous said...

Glad to hear you are feeling better.
Having experienced them firsthand, I agree, steroids are a wonder.

At Wed Feb 28, 01:19:00 PM, Blogger Radioactive Tori said...

Scoping is not much fun. When I had it done before my thyroid surgery I thought I was going to faint because I was so nervous about it. Luckily my doctor was amazing and talked me through it all.

I have been prescribed steroids twice and each time felt wonderful. I am a runner/swimmer and I noticed that while on them I was able to run/swim faster and for longer without getting tired. I was not able to sleep at all while on them though. I'm glad you are feeling better!

At Wed Feb 28, 09:12:00 PM, Anonymous Anonymous said...

Lucky you for being able to get a good night's sleep after a whopping dose of steroids. I've had a series of epidural steroids on 2 occasions for a disc herniation -- both times I felt good enough to return to work much earlier than was recommended, and both times had horrible insomnia for several nights.

Great job on grand rounds! (I enjoyed your interview, too.)

Artemis (still computer-less, but occasionally hitching a ride)

At Thu Mar 01, 09:38:00 AM, Blogger Dreaming again said...

Steroids are definitely a double edged sword.

Having been given them in high doses for Myasthenia ... when they tried to give them to me when I was diagnosed with lupus, I kept refusing ... I knew the nightmare they could be. I just couldn't see them helping that much.

Finally, the lupus got to the point I was desperate for anything to help, and agreed. No one had told me that the prednisone therapy with lupus is LOW DOSE therapy rather than HIGH dose that's used with Myasthenia!

Big difference. Now ..if you want to take my 5 mg a day away from me ...we're gonna fight.

I'm gonna win. MG & lupus beside ...

I still have to go on the huge doses for flares ...but I'm on the low dose for daily ...and it's a HUGE difference than the 60 to 100 mgs a day I'd be on for the MG.


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