The most frightening thing I ever heard a patient say was, I think the prednisone is making me want to hurt my kids.

Side Effects of Steroids

As always, Drs. Melton and Thomas have done a wonderful job putting together their annual Clinical Guide to Ophthalmic Drugs. But, I would like to add a note of caution to their enthusiastic support of oral corticosteroids. With regard to contraindications, they mention the need to ask about peptic ulcer disease and diabetes as well as the possibility of pregnancy.

What they fail to mention are the most common and life-disrupting side effects (outside of the GI effects). Those are insomnia and hypomania, and they most certainly do happen in patients on temporary oral steroid use.

As evidence, a recent meta-analysis showed that 6% of patients on short-term oral steroids suffered severe psychiatric reactions, and mild to moderate reactions affected 28% of patients.1 This certainly seems a high enough number to mention to patients you plan to start on oral steroid therapy.

The prudent doctor should always be aware of the 6% possibility of severe adverse effects of short-term steroid use, most notably the risk of steroid psychosis. The most frightening thing I ever heard a patient say was, I think the prednisone is making me want to hurt my kids. This was a 140lb female on 60mg of oral prednisone for a severe bilateral sarcoid uveitis. She had been on the prednisone for three days. Her internist put her on Celexa (citalopram, Forest Pharmaceuticals), which resolved her psychosis and allowed her to remain on the oral prednisone. But, those words are always in the back of my head whenever I write a prescription for oral corticosteroids.

Tom Stickel, O.D., St. Louis

Drs. Melton and Thomas respond:

Thank you for your kind remarks. Your points are very well taken. In all our years of treating patients with corticosteroids, we have only occasionally encountered patients who had a minimal adverse side effect from the drug.

As you know, the multiple side-effect potential of corticosteroids is highly stressed in formal training programs, and most practitioners are paralyzed in fear of such. Our Drug Guide is an attempt to share the beneficial reality of these healing agents. The vast majority of our patients have tolerated oral prednisone beautifully. We do, however, sincerely appreciate your pointing out the uncommon downside of this class of medicine.


Topical Rosacea Treatment

Soothe the Burn of Ocular Rosacea (June 2008), by Joseph Pizzimenti, O.D., and Carlo Pelino, O.D., provided a comprehensive approach to the diagnosis and management of this cantankerous disease. A timely adjunct should have included a review of the use and possible benefits of a new topical medication, AzaSite (azithromycin 1%, Inspire Pharmaceuticals). Although this drug was only recently introduced, it has already received much attention and there exists a wealth of literature supporting its use in the management of ocular rosacea. I have little doubt that this medicine will serve an important role in optometric offices. Our anecdotal experience with AzaSite for the treatment of acute episodes of ocular rosacea has been superb.

Elliot M. Kirstein, O.D., Cincinnati

Drs. Pizzimenti and Pelino respond:

Thank you, Dr. Kirstein, for your thoughtful comments. Previous work showed that oral azithromycin is a promising agent in the treatment of rosacea.2 Apart from its antibacterial activity, the oral form of azithromycin exhibits anti-inflammatory activity.

AzaSite is currently approved for the topical treatment of bacterial conjunctivitis. We have not come across any clinical trials or similar literature specifically showing a therapeutic effect of topical azithromycin in ocular rosacea patients. However, a recent clinical trial compared the safety and efficacy of two weeks of AzaSite treatment in combination with hot compresses in 21 patients with moderate to severe meibomian gland disease. The results showed that AzaSite in combination with hot compresses provided significant improvement over hot compresses alone.

Further clinical research is needed to establish the efficacy of topical azithromycin for the treatment of lid, meibomian and ocular surface inflammatory diseases in general. A well-designed clinical trial is also needed to establish the efficacy of topical azithromycin specifically for those patients with rosacea and its ocular complications.

All that said, the potential anti-inflammatory activity of AzaSite makes it a promising agent that may well contribute to our armamentarium against ocular rosacea.


1. Warrington TP, Bostwick JM. Psychiatric adverse effects of corticosteroids. Mayo Clin Proc 2006 Oct;81(10):1361-7.

2. Bakar O, Demiray Z, Grbz O. Therapeutic potential of azithromycin in rosacea. Int J Dermatol 2004 Feb;43(2):151-4.

3. Inspire Pharmaceuticals. AzaSiteResults from a 2-week phase IV clinical trial in meibomian gland disease (posterior blepharitis).

Vol. No: 145:08Issue: 8/15/2008