Friday, September 23, 2011

The Bad, Good Medication

“A long time ago, in my UW-Madison years, I used to share the ride home from campus with my neighbor, Bernie, a physician in the Division of Clinical Oncology. One day we were stopped at a traffic light and Bernie glanced at a passing pedestrian and said, ‘See that guy with the moon face. I’ll bet he’s on steroids.’ ‘If you say so, Bernie,’ and we continued on home.”

“That must have been your introduction to corticosteroid medications, Curmudge. Have you ever experienced them first hand?”

“Right hand as well as left hand, Jaded Julie. Tendonitis in several of my fingers was treated with cortisone injections. The pain was exquisite as the doc probed around with the needle inside each finger trying to locate the tendon. But I never had to take prednisone, the common oral corticosteroid that is the topic for today’s discussion.”

“Pray tell, O Unpredictable Oracle, why your brain decided to focus on prednisone, of all things.”

“Prednisone has been around since the 1950’s, and it is prescribed for a wide variety of conditions. Patients who are anywhere north of clueless probably have heard that there is something about prednisone that they won’t like, but they might not recall what it is. We are going to tell those patients what is in store for them by sharing what I have observed in the past year.”

“In my training I learned that cortisone is produced in the body’s adrenal glands, and its synthetic form is prednisone. It was originally hailed as a wonder drug for its effect on patients with rheumatoid arthritis, and it is used for other autoimmune diseases like multiple sclerosis and lupus. A valuable property of corticosteroids is their ability to prevent release of substances in the body that cause inflammation; that explains the injections into the tendons of your fingers. Other treated conditions include inflammatory bowel disease, some lung diseases, severe allergies, and asthma.”

“Because of its amazing versatility, prednisone is sometimes prescribed when nothing else seems to work…sort of a medication of last resort or a forlorn hope.”

“Forlorn hope? What is that?”

“It’s like a ‘Hail Mary’ pass, Julie, only an ‘incomplete’ has much greater significance for the patient.”

“Except for the ‘forlorn hope,’ everything we’ve said about prednisone sounds pretty good. What about side effects?”

“The package insert with most medications describes a lot of side effects that rarely occur. With prednisone, many of the side effects almost always occur, especially if the med is taken for many weeks or months. Most patients seem to gain weight around the middle and acquire the ‘moon face’ that my neighbor, Bernie, observed. You know how female patients feel about that. A patient with the beginnings of cataracts will find that they bloom dramatically and soon require surgery.”

“I’ve read, Curmudge, that mood changes are common and that prednisone tablets have been referred to as ‘nasty pills.’ Other threats are osteoporosis, increased susceptibility to infections, general malaise, and shaky handwriting. Prednisone even has side effects if one suddenly stops taking it. The body’s own corticosteroid factory goes on standby in the presence of an external source of the chemical, and it takes awhile for it to resume production.”

“I observed a patient entering a physician’s waiting room who had apparently been on prednisone long term for a lung condition. She was grotesquely obese, in a wheelchair, and clutching an oxygen cylinder with a plastic tube leading up to the cannula in her nostrils. I heard another patient whisper with fierce resolve, ‘I don’t want to ever be like that.’ Little did she realize that death was the only sure way to avoid that fate. Can’t you envision a patient’s final words before expiring, ‘At least I won’t have to take any more prednisone.’?”

"Yuk! What a morose ending. Can’t you think of a brighter way to conclude today’s discussion?”

“I can, Jaded Julie. It’s called ‘precision medicine.’ As we quoted Clayton Christensen in The Crystal Ball 5, it is ‘the provision of care for diseases that can be precisely diagnosed, whose causes are understood, and which consequently can be treated with rules-based therapies that are predictably effective.’ If society doesn’t stifle creativity, our grandchildren won’t have to be treated with medications that have as many side effects as benefits.”

“Halleluiah amen, Curmudge!”

Affinity’s Kaizen Curmudgeon

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