A Wonder Drug of Ill Repute

If I could only have one drug in my pharmacopeia, what would it be?

An antibiotic? A pain reliever? A happy pill? Keep guessing…

During my Saturday clinic I saw a man I had done a physical on two weeks before. He told me he had suffered from daily headaches for several years and was popping over the counter medications just about daily to no avail; he clearly had developed rebound headaches on top of his frequent migraines. In today’s appointment he announced he had been headache free for nearly a week from the ten day prescription I had given him.

I also saw a woman with hives from head to toe. I prescribed for her with absolute confidence that her symptoms would go away.

Another patient with what the rheumatologist called inflammatory polyarthritis was not doing well on methotrexate, but told me that while she was on prednisone before that, she felt normal.

A few days before I saw a sciatica patient whose leg pain had completely resolved within a week of his first visit with me.

The day before that I prescribed it for a woman with a flare up of multiple sclerosis.

Prednisone is truly a wonder drug. It treats allergies, sciatica, gout, eczema, intractable headaches, rheumatoid arthritis, inflammatory bowel disease, asthma and COPD exacerbations, chronic lymphocytic leukemia (at least when I was a medical student), cancer related hypercalcemia and a multitude of other conditions.

It is about as old as I am, and neither of us has many undiscovered secrets left.

In the case of prednisone, that is very comforting to me.

Younger doctors are more afraid of it than I am. I have seen a colleague with arthritis die from a newer medication due to pneumonia and sepsis. I worry about the way many of these newer agents can cause problems very suddenly; prednisone is a bit more predictable.

Years ago I had a British reader question my use of prednisone for acute gout. It is my go-to, better tolerated than colchicine and safer on stomach and kidneys than indomethacin.

It is amazing what steroids do, not only to rheumatological conditions but also to our pain perception. I liken their effect to the instant ability people have in times of crisis to exert more effort than any other time and never notice pain or weakness; it can give us the sudden ability to run faster than ever before, lift heavy objects that pin down an accident victim and so on.

In some arenas it has had a renaissance: I learned in school that it decreases our ability to fight acute infections, but now it improves survival in septic shock.

The problem is its side effects with long term use, but its versatility in acute care is amazing and I do think it would be the one drug, if had to pick a single one, in my extreme survival kit.

But, may I please have one or two more?

3 Responses to “A Wonder Drug of Ill Repute”

  1. 1 Harold March 25, 2019 at 12:22 pm

    After a recent severe flair up of Sciatica my doctor prescribed Prednisone. Before starting it the sciatic pain eased so I held off but eventually took it. Not sure that it did anything, could just have been time but I started to feel better. Only issue was that I developed a sore Achilles tendon. In researching that I noticed some info on a link between the two. Not entirely sure if one short course of Prednisone could be at fault or coincidence that I developed that after a lifetime of never having that tendinitis.

  2. 2 samharris March 25, 2019 at 7:08 pm

    What I really found interesting about this is the downturn of use of steriods. I’ve not been offered steroids for over twenty years. Do medications have a fashion sense? Do they go in and out of prescription depending on what the politics of the country are? You blow my mind Doc. But that’s not too difficult.

  3. 3 Andrew mackey March 27, 2019 at 8:29 am

    Thank you; after 40 years I often say Prednisone is my most treasured medication, and use low dose 10-20mg/d for 5-10 days for coughs!

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Osler said “Listen to your patient, he is telling you the diagnosis”. Duvefelt says “Listen to your patient, he is telling you what kind of doctor he needs you to be”.


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