Topical steroids: Awareness and misuse among patients, pharmacists and general medical practitioner.

AIMS AND OBJECTIVES: (1) To determine the level of awareness among patients, pharmacists and general practitioners about commonly available topical steroids and its combinations.(2) To determine the source of recommendation/prescription of topical steroids and its combination creams.(3) To know and create awareness about the side effects of topical steroids in all the study groups. METHODS: This was a prospective questionnaire-based study where three study groups, namely patients, pharmacists and general practitioners, were included. This study was approved by the institutional ethics committee. after ethical clearance. The patients who used topical steroids for dermatoses where it is an absolute contraindication, as well as those who developed side effects, were included in the study. ThoroughComplete cutaneous examination was done specifically to detect the side effects of steroids. Seminars were conducted and questionnaires were given to both the pharmacists and general practitioners of nearby areas. The questionnaire consisted of questions regarding their prescription and dispensing practices of topical steroids and its combinations. RESULTS: Out of 95 patients seen, the most commonly used steroid molecule was clobetasol propionate 0.05% in 44 (46.3%) patients, the common source of recommendation was general practitioners in 36 (37.8%), the common indication was superficial dermatophytosis in 85 (89%) and the most common adverse effect was recurrence/increase in the extent of the infection in 72 (75.78%) patients. Out of total 44 general practitioners enrolled in the study, 22 (50%) were qualified allopathic medical practitioners and22 (50%) were homeopathic/ayurvedic doctors. Superficial dermatophytosis [19 (43.18%)] was the common dermatosis seen by them. While 29 (65.90%) preferred prescribing topical steroids or its combination, rest of them preferred plain steroid creams. Out of 179 pharmacists, 74 (41.34%) did not have appropriate knowledge of topical steroids, 35 (19.55%) were not aware that steroids are isschedule "H" drugs. Commonest molecule sold over the counterwas clobetasol propionate 0.05% by 74 (41.89%). The limitations of our study were small study group and short duration. CONCLUSION: As dermatologists, it is our responsibility, to correctly educate the society, particularly the non-dermatologist medical fraternity, about ethical and rational use of topical steroids.

Relationship between corticotherapy and increased cardiac risk in patients with rheumatoid arthritis

Rheumatoid arthritis is an autoimmune inflammatory joint disease with global prevalence of 0.4% to 1.0%. Extra-articular manifestations increase its morbidity and severity, and cardiovascular diseases present the greatest risk. Therapeutic approaches have been used to treat rheumatoid arthritis, often involving the use of multiple classes of drugs with different mechanisms and forms of action. Corticosteroid therapy is widely used in this therapeutic combination; however, its use has been widely questioned because of its high toxicity and some negative effects, including the possibility of increased cardiovascular risk, depending on the dosage. Some studies have provided important insights into how glucocorticoids have an impact on cardiac complications in patients with rheumatoid arthritis. Most of these studies have concluded that exposure to these drugs at high or cumulative doses is associated with increased risk of death, as well as possibly being associated with the presence of a positive rheumatoid factor.

Myopathy following mechanical ventilation for acute severe asthma: the role of muscle relaxants and corticosteroids.

BACKGROUND: Acute myopathy following mechanical ventilation for near-fatal asthma (NFA) has been described recently, and some researchers have suggested that this complication is related to the use of neuromuscular blocking agents (NMBAs) and corticosteroids (CSs). OBJECTIVES: To determine the incidence of acute myopathy in a group of patients and to examine the most important predictors of its development. DESIGN AND METHODS: A retrospective cohort study over a 10-year period (1985 to 1995) of all asthma patients who received mechanical ventilation at two centers in Vancouver (designated center 1 and center 2). RESULTS: In center 1, there were 58 patients who had 64 episodes of NFA, and in center 2, there were 28 patients who had 30 episodes. NMBAs were used in 30 of 86 admissions for acute severe asthma (35%). The mean (+/- SD) duration of muscle paralysis was 3.1+/-2.3 days. A total of 9 patients (10.4%) developed significant myopathy. The incidence of myopathy was 9 of 30 (30%) among patients who received NMBAs. In a multiple logistic regression model, the development of myopathy was only significantly associated with the duration of muscle relaxation. The odds ratio for the development of myopathy increased by 2.1 (95% confidence interval, 1.4 to 3.2) with each additional day of muscle relaxation. The dose and the type of the CS were not significantly associated with the myopathy in the multiple logistic regression analysis. CONCLUSION: Our study showed that there is a high incidence of acute myopathy when NMBAs are used for NFA. The incidence of myopathy increases with each additional day of muscle relaxation.

A case series of abuse of a new opioid combination, Norjizak.

Cushing's syndrome results from lengthy and inappropriate exposure to excessive concentrations of either endogenous or exogenous glucocorticoids. This study described 30 patients with a novel type of severe exogenous Cushing's syndrome in a group of intravenous drug users due to illicit use and dependence on a new opioid combination, Norjizak. Thirty consecutive patients (2 women and 28 men) who presented with a novel type of severe exogenous Cushing's syndrome and other complications were admitted to the emergency departments of Qom and Isfahan University of Medical Sciences, Isfahan, Iran, between September 2005 and September 2007 were enrolled. All participating patients were intravenous drug users who used a narcotic drug called Norjizak, a combination of different opioids with dexamethason or benzodiazepines. Patients were first evaluated and managed based on the current illness, and then entered into a detoxification program by a medical team. Clinical data were collected by an open interview and the patient's files using a standard form. High-performance liquid chromatography was used to determined glucocorticoid existence in the brand. The major complaints and clinical findings were withdrawal symptoms, severe edema, osteoporotic fracture, impairment in glucose tolerance, decreased libido, and sepsis (including necrotizing pneumonia, cutaneous infection, multivalvular endocarditis, osteomyelitis, and urogenital infection). Most patients had started with 2 or 3 vials per day and then increased the dose compulsively to maximum of approximately 15 to 20 vials per day. The concentration of Dexamethhasone disodium phosphate in each 2 mL vial was 0.4 to 1 mg/mL. Heroin was also found in them. We are witnessing a special exogenous Cushing syndrome due to the mixing of opiates and dexamethasone. Norjizak syndrome is the clinical condition of poisoning with a second material when it is combined with opiates due to compulsive dose increment and long duration.

Muscle weakness in mechanically ventilated patients with severe asthma.

Patients who undergo mechanical ventilation for severe asthma are at risk of developing diffuse muscle weakness because of acute myopathy. The relative importance of corticosteroids and neuromuscular paralysis in causing the myopathy is controversial, and it is uncertain whether the chemical structure of the drug used to induce paralysis influences the risk of myopathy. Using a retrospective cohort study design, we evaluated 107 consecutive episodes of mechanical ventilation for severe asthma to assess (1) the incidence of clinically significant weakness in patients treated with corticosteroids alone versus corticosteroids with neuromuscular paralysis, (2) the influence of the duration of paralysis on the incidence of muscle weakness, and (3) the relative risk of weakness in patients paralyzed with the nonsteroidal drug atracurium versus an aminosteroid paralytic agent (pancuronium, vecuronium). The use of corticosteroids and a neuromuscular blocking agent was associated with a much higher incidence of muscle weakness as compared with the use of corticosteroids alone (20 of 69 versus O of 38, p < 0.001). The 20 weak patients were paralyzed significantly longer than the 49 patients who received a neuromuscular blocking agent without subsequent weakness (3.4 +/- 2.4 versus 0.6 +/- 0.7 d, p < 0.001). Eighteen of the 20 weak patients had been paralyzed for more than 24 h. The incidence of weakness was not reduced when paralysis was achieved with atracurium as opposed to an aminosteroid neuromuscular blocking agent. In conclusion, corticosteroid-treated patients with severe asthma who undergo prolonged neuromuscular paralysis are at significant risk for the development of muscle weakness, and the risk of weakness is not reduced by use of atracurium.

¿Cómo suspender terapia con glucocorticoides? / How to discontinue glucocorticoid therapy?

Numerosas patologías pediátricas, tanto agudas como crónicas, requieren tratamiento con glucocorticoides (GC) por tiempos variables. Estos fármacos constituyen el tratamiento de elección en cuadros tan variados como asma bronquial, enfermedades autoinmunes, alérgicas y en algunas patologías malignas, por su potente efecto antiinflamatorio así como por sus propiedades inmunomoduladoras. También se indican en prevención del rechazo a transplante, cuadros de aumento de presión intracraneana y shock séptico, por nombrar sólo algunos de sus múltiples usos. Si bien sus indicaciones así conu) su dosificación están relativamente claras para la mayoría de los pediatras, no ocurre lo mismo al momento de decidir la suspensión, existiendo para ello innumerables criterio, la mayor parte basados en experiencias empíricas personales. Para muchos esta situación constituye una interconsulta para el endocrinólogo infantil. Este artículo intenta ayudar al pediatra a decidir correctanwnte la suspensión de la terapia con GC en niños