There are many clues that can be gleaned from the medication lists that patients bring with them to clinic. "Hate, Hate steroids" read a note one of my patients had written for me at the bottom of her list. Of all the double-edged swords we wield in clinic, glucocorticosteroids (prednisone and others) engender the strongest feelings and the liveliest discussions.
The woman that wrote me the hate note regarding her steroids had several legitimate gripes against the medication. She hated them because of weight gain, but she also complained the medication made her feel "[an expletive that will henceforth be replaced with witchy]". Prednisone doesn’t have a monopoly on causing this type of side effect. Many medications that we prescribe open a Pandora’s box in the central nervous system and cause problems with moodiness, anxiety, and other issues. In my opinion, medications that are used for fibromyalgia are the most likely to cause these issues, or perhaps patients with fibromyalgia are more prone to have these issues.
It wasn’t readily apparent that my patient was having a problem with her mood, but patients are always on their nicest behavior when they see the doctor. Living in close quarters with these patients might be an entirely different and unpleasant experience. Our goal is to treat the patient, but sometimes an entire family suffers the side effects of our prescription. This is fertile ground for research. I could easily produce a visual analog scale to assess this frequently reported side effect and call this wonderful instrument the "Greenbaum Nastiness Scale." The patient instructions might read "Please choose a number between 0 and 10 in which 0 represents you in the best mood possible, while 10 represents you at your Wicked Witch of the West worst." Perhaps the National Institutes of Health will give me a grant to do further research on the depths of prednisone-induced human [witchiness].
This patient was also upset about facial swelling. In my notes, I had casually described her round face as "mildly cushingoid," but she certainly didn’t view this as a "mild" side effect. She puffed out her cheeks like a trumpet player to demonstrate how she felt she looked.
Although patients usually worry about weight gain, I think osteoporosis is the worst side effect of steroids. We typically prescribe additional medications to help prevent steroid-induced osteoporosis, but these are seldom popular prescriptions. An additional time-consuming discussion about calcium and vitamin D is usually necessary as well.
Ecchymoses, plum-colored bruises that pop up with minimal trauma, also affect the patient’s self image. Where there are ecchymosis, skin tears are usually not far behind. Sometimes patients ask questions like, "If this is what prednisone is doing to my skin, what is it doing to my insides?" These are difficult questions to answer, and invariably I deflect the question and fall back on my chorus of "We aim for the smallest possible prednisone dose for the shortest duration of time." Defining the contours of the smallest dose for the shortest duration of time is often a murky business. On countless occasions, I have given patients detailed instructions on how they should taper their prednisone, only to learn at their follow-up visit that they didn’t follow their instructions and their dose had remained the same for months. There are endless reasons for this resistance to dose changing. Sometimes, the problem is a flare-up of the underlying condition, but many times, it is because the instructions are too complicated for the patient, even when written instructions are given. Long ago, when I was less patient, or perhaps less realistic about patients’ ability to follow instructions, I was flabbergasted when a patient came back to clinic and was still taking the same dose of medication that she had been taking previously. I don’t know what I said to the patient, but I definitely remember leaving the exam room and telling the nurse to write the instructions backward on the patient’s forehead, so she would see them when she looked at herself in the bathroom mirror each morning. The nurse and I had a laugh about that, but such outbursts don’t accomplish anything.
Sometimes, patients ask me if the weight they gain will magically disappear after they go off steroids, and I have to disabuse them of this innocent notion. Breaking the bad news, I tell them that it’s easy to put weight on, but hard to take weight off. I strive to be tactful, but sometimes I get the impression that not every practitioner is ready for a diplomatic career.