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Principles of glucocorticoid therapy
  1. J Kirwan
  1. Academic Rheumatology Unit, University Division of Medicine, Bristol Royal Infirmary, Bristol, UK

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    Glucocorticoid therapy is one of the most widely used treatments in medicine, hence this volume is intended for “internists and the many subspecialists in internal medicine, as well as family physicians, paediatricians, and all who use corticosteroids in their practice”. This looks like an ambitious project, even before one sees the contents page. It draws together contributions written by the editors and 49 physicians, principally their colleagues in New York, USA and Edmonton, Canada. They fall into five sections—overview, basic science, effects in specific body systems (for example, the eye, the gastrointestinal tract), clinical usage (the largest section), and special management considerations. The editors aim to present “a systematic discussion of the use of corticosteroids in different organ systems, their side effects, and their use in special circumstances such as pregnancy and childhood.”

    The arrangement of the chapters is disjointed. This follows from the different writing styles and the varied depth of explanation and evidence put forward in support of comments and assertions. But more than this, it is as if the project were started a few years ago but languished while some sections remained unfinished, only to be completed (perhaps by new chapter authors) in a rush for publication. Thus the language and references seem a little dated in many chapters but up to date in others.

    The basic science section is very good. It is current (although the field is moving rapidly) and comprehensive. The chapter on chemical action advocates “glucocorticoids” as the preferred term, a recommendation recently promulgated by a EULAR working group1 and with which I concur. It was slightly irritating to have the words steroids, corticosteroids, glucocorticosteroids, and glucocorticoids used almost interchangeably throughout the book. In the reviews of the effects of glucocorticoids on various body systems, those dealing with the skeletal system and muscle inevitably came under my closest scrutiny. I thought them basically sound, but was disappointed that no references were made to the Cochrane Collaboration meta-analysis of treatment to prevent glucocorticoid induced osteoporosis . . . myopathy, etc.

    The chapter on effects of glucocorticoids on the endocrine system is excellent, but advocates changing to hydrocortisone to manage discontinuation of glucocorticoid treatment and avoid acute withdrawal symptoms. I would need to see the hard evidence before I followed this recommendation. The review of effects on behaviour omitted any consideration of beneficial outcomes. In the large section on clinical usage, covering 13 disease areas (renal, allergic, lung, etc) the chapter on replacement therapy by Robert Lustig (a paediatric endocrinologist from San Francisco, USA) stands out as providing a particularly good review of glucocorticoid physiology and disease replacement. A useful distinction is made between “replacement” therapy and “immune alteration” therapy, which is relevant to current thinking on the possibility that some rheumatological conditions may be deficient in glucocorticoid production.

    The chapter on rheumatic and autoimmune disorders describes the current use of glucocorticoids. A table offers general descriptions of typical treatment regimens in various rheumatic conditions. I felt a little uncomfortable that they might be used indiscriminately by inexperienced non-rheumatologists. The authors offer little evaluation of the evidence supporting the different uses. This probably reflects the way in which many of the chapters in this section are presented, but I found it interesting to gain a general overview of the approaches used by our physician colleagues. Singh and Tyrell’s chapter on treating infection is incisive, analytical, and full of evidence. It contrasts with that on the risk of infection in the special management section. Here many potential dangers are mentioned, but nowhere is the risk quantified. The chapter on “pulse” therapy suffers from not including the newer understanding about the mechanisms of action of glucocorticoids.

    This book contains delights and disappointments, roughly in equal measure. Half way through I wondered if it was worthwhile continuing—but by the end I was glad I had done so. It will not provide the reader with detailed arguments for particular therapeutic approaches, but it gives a fair picture of current practice.

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