STEROID COMPLICATIONS

Corticosteroid medications, such as Prednisolone, are effective in a wide range of disabling and life-threatening medical conditions. One of the more unpredictable, devastating and most litigated side-effects of therapy is Avascular (= Aseptic or Osteo-) Necrosis. The upper end or head of the femur (sometimes humerus) disintegrates and must be replaced by a prosthesis. 

The pathological process appears to be either blockage of small blood-vessels by fatty fragments released into the blood, or replacement of the bone marrow by fatty material[1]. Excessive alcohol intake shares this mechanism, as do a number of rarer pathological conditions. In avascular necrosis complicating decompression sickness after deep diving, on the other hand, the blood-vessel blockage is by air bubbles.

PRACTICE POINT Excessive alcohol intake may predispose to the development of steroid-induced avascular necrosis through a common mechanism.

This cumulative effect of alcohol is a medicolegal two-edged sword. If adequate warning was given, there may be finding of failure to mitigate; if the physician either did not warn or did not attempt clinically to detect alcohol abuse, negligence may be compounded.

A major difficulty with establishing corticosteroid causation is that a number of studies have shown that unusually high dosage[2], [3] is not necessary for the complication to occur, nor need the course be long[4]. Nevertheless, meta-analysis of 22 clinical research papers suggests that avascular necrosis occurs when the usual daily dose of corticosteroid is high, rather than when occasional large doses are administered[5]. The Canadian conflict between case-law and Evidence Based Medicine has been well summarised[6]. 

PRACTICE POINT Negligence may be found when the regular dose of steroid prescribed is clearly and persistently more than was necessary to control the disease.

Copyright © 2008 Electronic Handbook of Legal Medicine