JOIN USSteroids: The double-edged sword of the drug world
Unlike the known public health crisis due to indiscriminate use of antibiotics, the misuse of steroids is lesser known even though the consequences are debilitating and can even be fatal. One of the magic drugs of modern medicine, steroids have been around for more than 60 years, but scientific evidence on the extent of their inappropriate use in India is sparse.
The ballooning of mucormycosis, or black fungus, infections during the second surge of the Covid-19 epidemic has turned the spotlight on unsupervised use of glucocorticoids — steroids in scientific parlance — leading to serious health consequences.
According to the National Centre for Disease Control, Delhi, there were nearly 41,000 cases of mucormycosis and 3,100 plus deaths till June end. More than 50% of these patients had a history of steroid misuse and diabetes — the commonest side effect of being on high-dose steroids for an extended period.
"Steroids are life-saving drugs, but given in wrong environment and wrong doses, there could be dangerous side effects ranging from crippling osteoporosis, multiple fungal infections, thinning of skin, elevation of blood pressure and sugar, unwanted fat deposition and insulin resistance,” said Krishna Sheshadri, a senior endocrinologist at Apollo Hospital, Chennai.
Experts said before prescribing steroids, a doctor should find out whether steroids are indicative of the problem for which it is being prescribed, the shortest period of time to give the drug safely and what precaution should be taken. The Indian realities, unfortunately, are different.
Self-medication
In 1987, a review of drug prescriptions in numerous locations around India showed that glucocorticoids are inappropriately prescribed for presentations such as fever and infections with great frequency. Nearly 10% of private prescriptions and 5% of self-medicated drugs may include a steroid. Close to 40% of the self-medicated oral steroids were hidden in fixed-dose oral preparations with an antihistamine or bronchodilator as a combination.
"Overuse of steroids is a problem in India as many general practitioners give them because of the medicine’s ability to make symptoms disappear and give pain relief. Also, given in small doses, it imparts a sense of well-being because of which patients want to continue, and the doctors comply. And then suddenly the patient collapses,” said Nihal Thomas, a professor at Christian Medical College, Vellore, and co-author of one of the few Indian studies on steroid misuse.
Thomas and his colleagues Philip Finny, Lois Armstrong and Chandan Nalli from Duncan Hospital at Raxaul conducted a study in north Bihar a decade ago to understand the extent of such unsupervised use of steroids in the hinterlands. Since seeking medical help for chronic health problems like chronic obstructive pulmonary disease, asthma, joint pains and skin diseases was not an option for the poor, they either self-medicated or were given steroids by local practitioners (quacks). In a few cases, private doctors also prescribed steroids, but many such doctors were unaware of the long-term consequences of steroid use.
They found that glucocorticoids are easily available over the counter. Prednisolone and dexamethasone were most commonly misused. While the regularity and duration of drug use are of concern, what matters to the poor is that these drugs are cheap and available over the counter.
Prolonged use of steroids, Thomas says, can also make one dependent on the drug. It then becomes even more difficult for a doctor to take the person off steroids, which can’t be done all of a sudden. The tapering-off has to be a gradual process as sudden halt can be fatal. In many cases, doctors have to settle for a low-dose steroid for life in the bargain.
Judicious use
"Steroids must be used judiciously. Even in the ICU, its use should be stopped after three-four days once the inflammation is under control. But we do see cases where a doctor asks a patient to use it for 10 days and come back. The patient doesn’t return but continues to use the steroids for six months, triggering adverse effects,” observed V Mohan, chairman at Dr Mohan’s Diabetes Specialities Centre.
Skin diseases are another area where inappropriate use of steroids is widespread. “They are considered a panacea by lay persons for anything on the skin. Topical corticosteroids are the most widely sold topical drugs and an overwhelmingly large population buys them without any prescription,” said S B Verma, a veteran dermatologist based in Vadodara.
Topical corticosteroids used in combination with antifungal agents are very often potent molecules. They are available over the counter and are grossly abused, which includes buying over the counter and applying at will for weeks, months and sometimes years. This is thought to contribute significantly to the development of chronic, difficult to treat dermatophytosis (ringworm infection) which has been causing havoc in India for the past 8-9 years.
To prevent over-the-counter (OTC) sale of such skin ointments — there were 1,066 brands in 2014 and the numbers must have grown significantly in the last seven years — the Centre changed the rules to ensure that such drugs are sold only on prescriptions from November 1, 2018.
"But barely anybody follows the rules. Such medicines are still sold OTC. There is a virtual epidemic of fungal infections fuelled by such cocktail creams,” Verma said. The side effects of unsupervised use of topical corticosteroids include discolouration and thinning of the skin and local growth of hair.
Life-saving drug
Notwithstanding its inappropriate use, doctors are unanimous on the benefits of steroids as a valuable medicine when used cautiously. There are diseases wherein deficiency of glucocorticoids happen as a result of pituitary or adrenal disease and in such cases life-long glucocorticoids are required in small doses to save their lives. In fact, the spurt in mucormycosis happened when doctors realised steroids can improve the condition of Covid-19 patients low on oxygen saturation. As oxygen became scarce, many doctors resorted to using moderate to high doses of steroids, hoping it would help.
"The misuse happened when doctors prescribed high doses of steroids even when oxygen saturation level did not fall below 93-94. But they were also under tremendous pressure during the second wave,” said Arunaloke Chakrabarti, a professor at the Post Graduate Institute for Medical Education and Research, Chandigarh, and one of India’s foremost experts on fungal diseases.
Even before Covid, mucormycosis were present due to India’s love for sweets and apathy for blood sugar control. Major hospitals used to report nearly 50 cases a year. But the huge spike seen during the second wave, affecting the face and nose in many cases, was scary. Chakrabarti said there had been an increase in Aspergillus and Candida infections too due to steroid misuse, but there was no comprehensive data.
It’s time the government started collecting such data and bring in policies to control the use of steroids to save the country from such dreaded infections in future.