Correspondence

Images in Clinical Medicine: Corticosteroid Osteonecrosis

N Engl J Med 1995; 333:130July 13, 1995

Article

To the Editor:

Chin and Sarno (Feb. 23 issue)1 state, ``Osteonecrosis can also occur with short-term use of corticosteroids.'' This statement is inexact and incomplete, and it could be used unfairly by lawyers in malpractice suits.

My colleagues and I have reviewed the international literature for any evidence that short-term treatment (less than 2 weeks) with moderate doses of prednisone (starting at 40 mg per day given orally, with the dose reduced over a period ranging from 6 to 14 days) in adults is associated with osteonecrosis. My experience is that this association is not present in a specific subgroup of patients. My colleagues and I are satisfied that in otherwise healthy people with asthma, chronic sinusitis, nasal polyps, or atopic dermatitis, osteonecrosis of bone is not a complication of prednisone treatment as outlined above.

Short-term treatment with corticosteroids may induce osteonecrosis in patients given very high doses, such as patients with head injuries and cerebral edema or those with multiple bone and joint injuries. Osteonecrosis also appears to be more likely among alcoholics and is certainly more likely in patients with collagen disease, such as systemic lupus erythematosus or rheumatoid arthritis.

It is important that this issue be clarified, because doctors may be unfairly judged and punished in courts of law for using a valuable therapeutic regimen in patients with diseases that are debilitating and potentially serious. A short-term regimen of moderate doses of prednisone is used in children as well as adults, also with no evidence of osteonecrosis when the guidelines outlined above are followed.

Allan Knight, M.D.
Sunnybrook Health Science Centre, Toronto, ON M4N 3M5, Canada

1 References

1. 1

   Chin CT, Sarno RC. Corticosteroid osteonecrosis. N Engl J Med 1995;332:511-511
   Full Text | Web of Science | Medline

To the Editor:

The knee radiographs by Chin and Sarno showing osteonecrosis are excellent teaching aids. However, the term corticosteroid osteonecrosis indicates an unequivocal relation between corticosteroid therapy and osteonecrosis, which oversimplifies the issue. Osteonecrosis had been described by 1888, over 60 years before the era of corticosteroid therapy.1 Almost 90 percent of patients with nontraumatic osteonecrosis have not received corticosteroids,2 and osteonecrosis does not develop in most patients who do receive corticosteroids. The risk of osteonecrosis in patients with pulmonary disease or head injuries who receive high-dose corticosteroid therapy has been calculated to be quite low: 0.03 to 1.2 percent.3-5

It is important to set the record straight on this point, because the assumption of absolute causation between corticosteroid use and osteonecrosis places an unjustified onus on all physicians who prescribe corticosteroids.

Lawrence N. Parker, M.D.
University of California, Irvine, Long Beach, CA 90822

5 References

1. 1

   McCarthy EF. Aseptic necrosis of bone: an historic perspective. Clin Orthop 1982;168:216-221
   Web of Science | Medline

2. 2

   Patterson RJ, Bickel WH, Dahlin DC. Idiopathic avascular necrosis of the head of the femur: a study of fifty-two cases. J Bone Joint Surg Am 1964;46:267-282
   Web of Science | Medline

3. 3

   Kenzora JE, Glimcher MJ. Accumulative cell stress: the multifactorial etiology of idiopathic osteonecrosis. Orthop Clin North Am 1985;16:669-679
   Web of Science | Medline

4. 4

   Parker L, Charter R, Wenjen M. A re-examination of the relationship between glucocorticoid therapy and avascular necrosis. Exp Clin Endocrinol 1991;10:59-61
   

5. 5

   Richards JM, Santiago SM, Klaustermeyer WB. Aseptic necrosis of the femoral head in corticosteroid-treated pulmonary disease. Arch Intern Med 1980;140:1473-1475
   CrossRef | Web of Science | Medline

Citing Articles (2)

Citing Articles

1. 1

   C. S. Murray, B. Simpson, G. Kerry, A. Woodcock, A. Custovic. (2006) Dietary intake in sensitized children with recurrent wheeze and healthy controls: a nested case-control study. Allergy 61:4, 438-442
   CrossRef

2. 2

   D. Alan Shewmon. (2000) Coma Prognosis in Children. Journal of Clinical Neurophysiology 17:5, 457-466
   CrossRef