Self-medication with steroids leads to Cushing’s for 5 in Yemen
Patients taking glucocorticoids without prescription developed syndrome
Unrestricted access to glucocorticoids, such as dexamethasone, and self-administration without prescription can lead to Cushing’s syndrome, a case series from Yemen showed.
“The education of physicians, pharmacists, and patients is necessary to avoid this problem,” the researcher who conducted the study wrote. “Physicians should keep this in mind and question patients very carefully about taking steroids in different forms before starting work-up for endogenous Cushing’s syndrome.”
The study, “Unintentional dexamethasone and steroid abuse among Yemeni patients: a case series,” was published in the Journal of Clinical and Translational Endocrinology: Case Reports.
Cushing’s syndrome refers to any condition caused by excessive levels of the hormone cortisol, which helps to regulate a wide range of processes throughout the body. Its most frequent form, exogenous Cushing’s syndrome, is caused by exposure to certain medications, typically glucocorticoids. Another form, Cushing’s disease, occurs when a pituitary tumor — a gland located at the base of the brain — produces too much adrenocorticotropic hormone (ACTH), which in turn stimulates excess cortisol production.
“The unrestricted availability of dexamethasone and other steroid preparations in Yemen has led to widespread unintentional steroid abuse, resulting in severe complications and irreversible hypoadrenalism in many patients,” the researcher wrote. “Raising awareness among healthcare providers and the general public is essential to mitigate this issue and ensure appropriate use of glucocorticoids.”
Patients turn to dexamethasone to treat asthma, cough, dry skin
The study described the cases of five patients who developed symptoms of exogenous Cushing’s syndrome — when the disease is caused by medications — due to abuse of glucocorticoids.
In one case, a 40-year-old man came to the emergency room with bronchial asthma, and was treated with dexamethasone delivered into the vein. His symptoms initially lessened, but he soon developed recurrent wheezing. Rather than seeking medical follow-up, he began self-administering dexamethasone injections every one to two days for two years, attempting to prevent the severe weakness he experienced whenever he stopped the medication. He was ultimately diagnosed with Cushing’s syndrome, and the corticosteroid therapy was discontinued.
Follow-up blood work revealed that the man had low levels of morning cortisol and ACTH, which normally signals the adrenal glands to produce cortisol. These findings suggested he developed adrenal insufficiency, a condition in which the adrenal glands fail to produce sufficient levels of certain hormones. He was prescribed dexamethasone, initially as an infusion and then orally, and recommended to taper the dose, if tolerated, after two weeks. However, the patient was lost to follow-up and had not been seen in the last six months.
In another case, a 25-year-old man had been self-administering dexamethasone every two to three days for more than a year. He had been prescribed the drug during an emergency department visit for an upper respiratory infection. When he eventually saw an endocrinologist, he had severe Cushingoid features, low blood pressure, and high blood sugar. He was switched to a daily dose of oral dexamethasone at 2 milligrams, which was later tapered to 1 mg. His attempts to transition to a safer medication were unsuccessful. Blood work confirmed he had adrenal insufficiency, and he was prescribed prednisolone at 5 mg daily. He remained on this treatment for two months, during which his condition was evaluated.
Dexamethasone syrup was determined to be the cause of Cushing’s for a 55-year-old woman, who had been taking the syrup daily for several years. The medicine was initially prescribed for a cough, but she continued using it without oversight. Her symptoms included classical features of Cushing’s. Transitioning her off the medication proved difficult due to the suppression of the hypothalamic-pituitary-adrenal axis — a complex network of pathways that controls the production of several hormones, including cortisol — which never recovered.
Several stores in Yemen sell honey and herbal mixtures purported to promote weight gain and increase energy. However, these mixtures may illegally contain steroids. A 28-year-old woman visited a clinic due to violaceous striae (purple stretch marks) on her abdomen and legs. She was referred to an endocrinologist to rule out possible Cushing’s disease, as her symptoms were consistent with Cushing’s. She initially denied using any medication, but later admitted to taking a honey mixture — suspected to contain dexamethasone — for weight gain. Her cortisol levels returned to normal after she stopped taking the mixture, but she was initially reluctant to accept that it was the cause of her problems.
A 25-year-old man saw a doctor for violaceous striae on his abdomen. Blood work showed low fasting cortisol levels, and no further tests were conducted. He denied using steroids, including injections or tablets, and reported only taking prescribed medications. During a follow-up two weeks later, he revealed that he had been using a cream for his severely dry skin. The cream containing a corticosteroid had been obtained without a prescription and was used several times a day for months. He stopped using it while on vacation, and his cortisol levels normalized. He was advised not to use steroidal creams without medical supervision.
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