British Journal of Rheumatology 1997;36:91–94
CORTICOSTEROID USE AND ABUSE BY MEDICAL PRACTITIONERS
FOR ARTHRITIS AND RELATED DISORDERS IN PAKISTAN
A. Z. FAROOQI, NASIR-UD-DIN, R. AMAN, T. QAMAR and S. AZIZ
Department of Rheumatology and Physical Medicine, Pakistan Institute of Medical Sciences, Islamabad, Pakistan
SUMMARY
A total of 256 consecutive patients attending our out-patient clinic in Islamabad, Pakistan, with complaints of pain in or around
the joints were evaluated for use of corticosteroids prescribed by medical practitioners they had seen earlier. The appropriateness
of such prescriptions and their consequent effects were assessed. Of the 256 patients, 110 (i.e. 42.5%) were identified as steroid
users; some of them were suffering from conditions known to be unresponsive to this form of therapy. One hundred and one
of the 256 patients had rheumatoid arthritis and 67% of these had been using steroids, mostly in an irrational manner. The
general practitioners and consultants (all non-rheumatologists) were responsible for the majority of steroid prescriptions. Steroid
side-effects were observed in 42/110 (38.2%) cases. This prevalent practice in Pakistan is a reflection of the state of affairs in
developing countries, and indicates a need for improvement and better regulation of health care in such countries.
K : Corticosteroids, Treatment of arthritis, Steroid prescription, Steroid side-effects, Pakistan.
C were introduced for the treatment of
rheumatoid arthritis by Philip Hench in the late 1940s
[1, 2]. The initial enthusiasm about their apparent
success was soon tempered by the realization that there
was a heavy price to pay for their continued use, in
terms of their side-effects [3, 4]. Standard rheumatology
texts today advocate their use in Q5% of cases of
rheumatoid arthritis (RA) [5]. In clinical practice,
however, they tend to be used in a greater percentage
[6, 7], mainly because of the perceived need in the
individual patient and the growing impression that
low-dose steroid therapy is associated with far less risk
of side-effects than initially thought [8, 9]. Irrational
use, even in low dosages, can still cause unacceptable
side-effects and this is commonly observed in countries
with loosely audited health care systems, e.g. the
developing countries [10]. Pakistan is a representative
Third World nation and in order to document the
pattern, extent and consequences of steroid use for
arthritis in this part of the world, this study was
undertaken at our institute in Islamabad.
patients to serve as an aide-mémoire to help in
identifying their past or present use. Whereas it was
possible, in most instances, to ascertain usage (or
otherwise) of steroids if the patient had only sought
alopathic care earlier, it was not so clear whether
traditional healers had been involved as well because of
their practice of handing out medicines in powdered
rather than tablet form. Strong suspicion of use was
aroused, of course, if the patient presented with a
Cushingoid appearance or had dermal atrophy
suggestive of chronic steroid ingestion.
The questionnaire used as our survey instrument was
completely devised by us and has not been validated in
any earlier survey. We found it useful and easy to apply
without leaving too many ambiguities.
RESULTS
Disease categorization of the survey population and
the numbers of those who were prescribed steroids are
shown in Table I. This table accounts for definite or
probable use of steroids as assessed by us. The
category-wise sources of prescription are shown in
Table II; this may underestimate the contribution of
traditional healers for the reasons mentioned above.
The overwhelming majority of prescriptions (78/
110 = 71.7%) were for oral use of steroids. A total of
13.8% (16/110) of patients had been given injectable
steroids. These were mostly i.m. and the rest
intra-articular; none were i.v. An equal number of
patients, i.e. 13.8%, were given a combination of oral
and injectable steroids.
Patients in Pakistan usually carry their medical
records (patchy as they are) with them. Scrutiny of
these revealed that a specific diagnosis was available at
the time of the initial steroid prescription in only 23.6%
(26/110) of cases; 38.2% (42/110) definitely did not
have a proper diagnosis and it was difficult to establish
this fact in another 38.2%.
Laboratory and radiological work-up to establish a
working diagnosis before embarking upon specific
METHODS
A total of 256 consecutive patients attending our
clinic with pain in and around the joints were studied.
All patients aged over 13 yr were eligible for entry into
this survey. The survey questionnaire (see the
Appendix) was designed to assess the duration of
symptoms, type of medical care sought earlier, use of
steroids and the pertinence of such a prescription, and
the recognizable side-effects of steroid therapy.
Disease diagnosis was made by the consultant
rheumatologist (AF). Detailed interviews were carried
out with the help of the survey questionnaire. Samples
of various types of steroid tablets were shown to the
Submitted 11 October 1995; revised version accepted 25 June 1996.
Correspondence to: A. Z. Farooqi, Department of Rheumatology
and Physical Medicine, Pakistan Institute of Medical Sciences,
Islamabad, Pakistan.
= 1997 British Society for Rheumatology
91
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BRITISH JOURNAL OF RHEUMATOLOGY VOL. 36 NO. 1
TABLE I
Disease categorization and steroid prescription
Disease category
No. of
cases
Ankylosing spondylitis
Juvenile rheumatoid arthritis
Chronic low backache
Palindromic rheumatism
Psychogenic rheumatism
Sciatica
Cervical spondylosis
Mixed connective tissue disease
Pseudogout
Tenosynovitis
Rotator cuff syndrome
Gout
Hypermobility syndrome
Psoriatic arthritis
Reactive arthritis
Non-specific arthritis
Osteoarthritis
Rheumatoid arthritis
Total
TABLE III
Dosages of steroids prescribed
Steroids
used
Percentage
of total
1
1
1
1
1
1
2
2
2
2
3
3
3
6
9
26
91
101
1
1
0
1
0
0
0
0
0
0
0
2
0
1
2
5
30
67
100
100
0
100
0
0
0
0
0
0
0
67
0
17
19
20
33
67
256
110
42.5
therapy was missing in 48.6% (54/110) of the cases.
Nearly a third (34/110 = 31.5%) did have some
documentation indicating attempted work-up and we
could not be sure of such past efforts in the remaining
20% (22/110) of steroid takers. It was not possible for
us to establish the exact clinical condition of the patient
at the time of the initial steroid prescription because of
the inadequate medical records.
Most (60/110) of the steroid prescriptions were for
short-term (1–3 weeks) use only, but a significant
number (26/110) were on continuous steroid therapy.
One-fifth of the patients (21/110) were using steroids
on an intermittent basis since their first prescription.
The majority of the prescriptions were for dosages
ranging from 5 to 20 mg of prednisolone/day
(Table III). The pattern of use in three patients who
had only been to traditional healers earlier could not
be determined.
Quite alarmingly, we found that nearly a third of
patients with osteoarthritis of the knees were given
steroid prescriptions in the past; 22/91 of these had
been given oral steroids (range 5–20 mg) and the
remainder (8/91) had been given intra-articular
injections. It appeared that these injections were given
at times of increased mechanical pain in the knees
rather than at times of acute synovitis complicating the
pre-existing osteoarthritis.
Dose (in mg equivalent of
prednisolone)
E5 mg
5–10 mg
10–20 mg
q20 mg
Tapering course
Indeterminate
Total
Source of steroids
Hospital-based medical officers
Traditional healers
Consultants
General practitioners
No. of
patients
Percentage of total
prescriptions
4
9
34
63
3.7
8.2
31.2
53.8
Percentage
of total
30
31
27
9
6
7
27.3
28.7
24.8
8.2
5.5
4.9
110
100
Specific attention was focused on the appropriateness of the use of steroids for patients suffering from
RA. They had comprised 101/256 of our study
population and 67% of them had been given steroids
in a dosage pattern as indicated earlier. We found that
nearly all these patients had had the drug prescribed
before the use of disease-modifying anti-rheumatic
drugs (DMARDs) was considered. Even the injectable
forms of steroids were used as a quick-action substitute
for oral therapy rather than measure up to the
generally accepted bolus dosages [11–13] which may
have been taken as remission-expediting therapy if
DMARDs were also to be prescribed. A total of 15/67
(22.3%) were given a prescription of steroids plus a
non-steroidal anti-inflammatory drug (NSAID) at their
first visit to the medical practitioner. Three out of 67
(4.5%) were given steroids even before the use of an
NSAID was considered and 42/67 (62.7%) were given
steroids if the NSAID was considered ineffective in the
first instance. Only nine of this group of 67 patients
with RA went on to be prescribed DMARDs (and
those too only by consultants) at a later stage.
Of the 110 patients identified as having been
prescribed steroids, we assessed that 38.2% (42/110)
exhibited one or more side-effects of this treatment
(Table IV). These included 22/26 of those who had
been on continuous therapy (10–20 mg/day), 15/21 of
the category who were on intermittent therapy and 5/7
of those in whom we could not ascertain the dosage
and pattern. These side-effects were seen at all the
dosage patterns recorded (especially if the use was
continuous in nature). Their frequency rose with the
amount ingested.
TABLE IV
Steroid side-effects observed
Side-effects
TABLE II
Sources of steroid prescriptions
No. of
patients
Cushingoid appearance
Hypertension
Cataract
Generalized osteoporosis
Dermal atrophy
Steroid-induced diabetes
Steroid-induced myopathy
No. affected
32
12
5
3
3
5
1
The total no. of patients prescribed steroids was 110.
The above-mentioned side-effects were seen in a total of 42
patients, either alone or in varying combinations.
FAROOQI ET AL.: CORTICOSTEROID USE IN PAKISTAN
DISCUSSION
It is clear from our results that the use of steroid
therapy for arthritis and related disorders is much more
widespread in Pakistan as compared to the documented practice in the West. What is most alarming is
the observation that in a number of instances (e.g.
one-third of OA cases) the local practitioners seemed
unable to differentiate between steroid-responsive and
steroid-unresponsive conditions.
The issue of steroid use for RA was dominated by
emotional discussions in the early days because of the
observed adverse reactions (usually with dosages
q20 mg/day or their equivalent) [3, 4]. This led to a
generalized reduction in the number of steroid
prescriptions. Their use became restricted to those with
advanced RA or suffering from systemic complications
of this disease. With time, experience with their
cautious use has grown and the relative safety of using
corticosteroids in low dosages for RA emphasized [14].
A recent study even advocates the use of low-dose
(7.5 mg/day) prednisolone therapy as a means of
modifying disease progression in RA [15]. Today, the
use of steroid therapy for RA is accepted universally by
rheumatologists as part of the overall disease
management programme, which usually includes
DMARDs as well. The non-rheumatologists, even in
Western countries, often resort to short-term oral
steroid use when confronted with an acute flare-up or
increased joint pain in a patient with RA. This practice
is not considered as safe as bolus i.m. or i.v. use because
of the relatively greater number of adverse effects. If
given at an early stage of arthritis of unknown cause,
this may also serve to obscure the true diagnosis for a
considerable time period. In countries where such
drugs can be bought over the counter, the patients may
be enticed to repeat the steroid prescription themselves
and thus start a vicious cycle resulting in undue
complications.
The fact that 54.5% of the steroid prescriptions
were for a short duration (1–3 weeks) indicates a
circumspect approach by the Pakistani doctors. It
probably reflects a balance between the historical
stigma of known adverse effects of steroids and the
perceived need to provide quick relief to patients who
are generally too poor to afford the expenses of
diagnostic tests and also not educated enough to
appreciate the benefits of long-term management
programmes. However, the observation that 38.2% of
patients on steroid therapy developed side-effects
indicates that these were used in an irrational manner
and should serve as a regretful warning against the
profligate use of steroids. Iatrogenic Cushing’s
syndrome was seen in 29% of the steroid users and
getting such patients back to some sort of normalcy
remains one of our greatest therapeutic challenges.
Studies advocating the use of steroids in low dosages,
including the one by Kirwan [15], acknowledge that
adverse effects can be seen with such regimens if
patients are not properly selected. Our study further
proves this point.
93
The sources of these (mostly irrational) prescriptions
were the general practitioners and consultants.
Perhaps this reflects the unrestrained behaviour in an
environment which is devoid of checks and balances,
and free of the fear of litigation. The consequent poor
results are a strong reason for the erosion of the
public’s confidence in our profession. Our services tend
to be equated with the unscientific medicine practised
by the traditional healers and should be a cause for
concern for all doctors working in countries with a
similar working environment.
The lack of rheumatology training and facilities in
Pakistan has been documented earlier [16]. The newly
formed Pakistan Society for Rheumatology proposes
to create better awareness of the magnitude of
problems and their solutions through education of
their fellow physicians. Seminars and workshops are
being arranged in different cities, and the policy makers
are being gradually convinced of the need to establish
more rheumatology centres in the country.
R
1. Hench PS, Kendall EC, Slocumb CH, Polley HF. Effects
of cortisone acetate and pituitary ACTH on rheumatoid
arthritis, rheumatic fever and certain other conditions.
Arch Intern Med 1950;85:545–666.
2. Hench PS. The reversibility of certain rheumatic and
non-rheumatic conditions by the use of cortisone or of
the pituitary adrenocorticotrophic hormone. Ann Intern
Med 1952;36:1–38.
3. Bollet AJ, Black R, Bunim JJ. Major undesirable
side-effects resulting from prednisolone and prednisone.
J Am Med Assoc 1955;158:459–63.
4. Curtess PH, Clark WS, Hendon CH. Vertebral
fractures resulting from prolonged cortisone and corticotrophin therapy. J Am Med Assoc 1954;156:
467–79.
5. Carson DW. Drug treatment of rheumatoid arthritis. In:
Scott JT, ed. Copeman’s textbook of the rheumatic
diseases, 5th edn. Edinburgh: Churchill Livingstone,
1978:404–6.
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rheumatoid arthritis—the fiction and the fact. Br J
Rheumatol 1985;24:164–6.
7. Friesen WT, Hekster YA, van de Putte LBA, Gribnau
FWJ. Cross-sectional study of rheumatoid arthritis
treatment in a university hospital. Ann Rheum Dis
1985;44:372–8.
8. Saag KG, Koehnke RN, Caldwell JR et al. Low dose
long-term corticosteroid therapy in rheumatoid arthritis:
an analysis of serious adverse events. Am J Med
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APPENDIX
Survey questionnaire to determine the pattern and consequences of corticosteroid use in Pakistani patients with arthritis or related complaints
Question
1. Duration of symptoms at time of survey?
2. Nature of symptoms since onset?
3. Maximum no. of joints involved?
Response variables
14. Detectable side-effects of past steroid use?
Months/years
Intermittent; continuous; initially intermittent
One joint only; up to four joints; more than four
joints
Traditional healer
General practitioner
Hospital medical officer
Consultant
Definite (documented)
Probable (description)
None
Traditional healer
General practitioner
Hospital medical officer
Consultant
Oral
Injectable (im/ia/iv)
Both
Short term (1–3 weeks)
Intermittent since onset
Continuous since onset
Indeterminate
On 1st visit
Before NSAIDs
Before DMARDs (RA only)
5 mg or less
5–10 mg
10–20 mg
More than 20 mg
Tapering course
Indeterminate
Yes
No
Unclear
Yes
No
Not sure
Yes (by whom)
No
List
15. Final disease diagnosis after evaluation at Pakistan Institute of Medical Sciences?
–
4. Type of medical advice sought earlier?
5. History of steroid use in the past?
6. Steroids prescribed by?
7. Type of steroids received?
8. Duration of steroid use?
9. Phase of therapy at which steroids were prescribed?
10. Dosages of steroids employed?
(in equivalent mg prednisolone)
11. Availability of specific diagnosis at time of initial steroid prescription?
12. Laboratory or radiological work-up before prescription of steroids?
13. In case of RA, were DMARDs ever used?
The answers to these questions were written after the interviewer had verified as much as possible from the patient and the available records,
and then used his/her own judgement as to the most appropriate response variable.