CENTRAL  SOUTH  DAKOTA  MEDICAL NEWS
THE CLINICAL VIEW
By: Phillip E. Hoffsten, M.D.
12/2/2000

 Cortisone - The Good and the Bad

In all of medicine there is perhaps no drug more controversial than cortisone. It is a wonderfully useful, very potent medication that unfortunately has terrible side effects if used inappropriately. Guns and cortisone have a lot in common; they both can have terrible effects if placed in the hands of the wrong people or for the wrong purpose.

Cortisone is a naturally occurring hormone that is produced by the adrenal gland in everyone. It is an essential hormone. In 1855, Dr. Addison was the first to describe the result of adrenal failure and the absence of cortisone. He described the case of several people who died because they did not have enough cortisone. On the other side of the coin is a condition called Cushing's disease in which the person naturally makes too much cortisone for themselves and has all of the side effects that we eventually learned come from excess cortisone.

What are the benefits of cortisone and why is it such a useful medication? First of all, it is the best antiallergic medication that medicine has.    In the fall or in the spring when those pollen-related allergies develop, an injection of slow release cortisone can often turn the symptoms off completely. The itchy dry eyes, the runny nose and other allergic symptoms simply stop.

A second use of cortisone and one that is life saving is the prevention of transplant rejection. There are thousands of individuals in the United States who have had a kidney transplant. For the last 40 years, the best and most predictably effective medication to prevent rejection of the kidney transplant is the use of cortisone. The same is true for heart transplants and liver transplants and lung transplants.

A third major use for cortisone is the prevention of inflammatory arthritis. When an individual has a flare of rheumatoid arthritis or gouty arthritis or inflammatory osteoarthritis, a brief course of cortisone can stop the symptoms very quickly alleviating the pain and stiffness that comes with any movement.

The list of less frequent uses of cortisone could go on and on. Briefly, it is very useful to stop swelling of the brain in people who have suffered head trauma. It is very useful to stimulate the bone marrow in individuals who have damage to their bone marrow and cannot make blood in a normal way. It is very useful for individuals who have severe lung disease and have difficulty breathing because of infections and asthma. Treatment with cortisone can stop asthmatic symptoms when nothing else will. Cortisone is thus a wonderfully useful drug and very effective when used appropriately.

Why are there so many warnings about the use of cortisone? In 1948, the Mayo Clinic began to use cortisone to treat rheumatoid arthritis. In this condition, the person's joints become swollen, chronically deformed, very painful and to that time only responsive to the use of aspirin-like products. When cortisone was first given to rheumatoid arthritic patients, it seemed like a miracle with the relief that they experienced. The red, hot, swollen, painful joints simply receded and the pain stopped. Unfortunately, when the cortisone was stopped the disease seemed to recur and so cortisone became something was used over months of time and even years of time in some individuals. By the early 1950s, just several years after the drug's use had been started, it was recognized that terrible side effects were developing. It should be noted that these side effects come from the chronic use of the medication over weeks and months and years rather than from short one week or two weeks use of the medication. A brief administration of cortisone for two weeks has vanishingly few side effects. A prolonged course of cortisone over several months has guaranteed side effects.

The side effects of cortisone used on a long-term basis include:

1.         Thinning of the skin and easy bruising especially on the forearms.

2.         Decreased muscle mass with wasting of the arms and legs.

3.         Increased appetite and weight gain.

4.         High blood pressure.

5.         Cataracts with the need to remove the lens of the eye and replace it.

6.         Low blood potassium levels with muscle aching and cramps.

7.         Severe osteoporosis.

8.         Degeneration of the hip joints with the need to replace with an artificial hip.

9.         Decreased growth in children.

10.       Increased incidence of severe infections.

With all of these terrible side effects, why would anyone ever use cortisone? As mentioned above, the drug has some wonderful anti-inflammatory components and in the case of kidney transplant patients, it is the drug that keeps them alive and prevents kidney transplant rejection. Healthcare professionals are aware of the problems of cortisone use and carefully try to get the dose as low as possible and limit the time of use to as short as possible. In the case of a transplant or a severe asthmatic or someone with polymyalgia rheumatica, long-term use is going to be necessary to prevent the disease process.

Dealing with the side effects is possible. One step is to be sure to use a double dose of vitamins daily so that at least 800 units of vitamin D are obtained. Cortisone interferes with the normal function of vitamin D but simply doubling the dose of vitamin D daily to 800 units reverses this side effect. Monitoring blood pressures and treating them appropriately when they are found to be elevated can prevent that side effect. Dietary discretion and attention to weight gain can be very difficult and requires an insight and discipline on the part of the patient. Maintaining an exercise program can help preserve muscle mass.

In summary, cortisone itself is neither good nor bad. It is how it is used and for what length of time and for what purpose that decides whether the person will have net benefit or net harm from a medication such as this. The healthcare professionals at your clinic are aware of the side effect profile of cortisone and can help in avoiding medication problems.