Clinical Review Lesson of the week

Depot corticosteroid treatment for hay fever causing avascular necrosis of both hips

BMJ 2001; 322 doi: http://dx.doi.org/10.1136/bmj.322.7302.1589 (Published 30 June 2001) Cite this as: BMJ 2001;322:1589
  1. S M S Nasser, senior registrara,
  2. P W Ewan, consultantb (Pamela.ewan@addenbrookes.nhs.uk)
  1. a Department of Medicine, University of Cambridge Clinical School, Addenbrooke's Hospital, Cambridge CB2 2QQ
  2. b Department of Allergy and Clinical Immunology, Addenbrooke's Hospital
  1. Correspondence to: P W Ewan
  • Accepted 8 March 2001

Consider immunotherapy rather than depot corticosteroid treatment for hay fever

The prevalence of hay fever (seasonal allergic rhinitis) has increased dramatically over the past four decades in the United Kingdom, with a doubling from 10 per 1000 people in the 1970s to 20 per 1000 in the 1980s.1 The British Society for Allergy and Clinical Immunology has published guidelines on the management of rhinitis that recommend that, when measures for avoiding pollen are insufficient, treatment should be either oral or topical antihistamine, to be taken as required, or topical sodium cromoglycate, to be taken regularly.2 If these treatments are ineffective, intranasal corticosteroids should be taken regularly, with oral or topical antihistamines added if required. If this stepped programme is adhered to the vast majority of patients will respond, but if patients fail to respond systemic corticosteroids may be used.

Over the last few decades the practice of treating severe symptoms with depot corticosteroids has become common, mainly because the duration of treatment of 4–6 weeks is often sufficient to cover the whole season. If the season is exceptionally severe or the patient experiences prolonged symptoms as a result of multiple allergies (for example, a combination of tree and grass pollen allergy), more than one depot corticosteroid injection may be required. Oral corticosteroids are less commonly used, perhaps because of the inconvenience of taking daily medication for 6–8 weeks every year.

The United Kingdom is unusual in the developed world in that it has minimal provision of allergy services, hence only small numbers of patients with severe seasonal allergic rhinitis have access to immunotherapy despite the growing evidence for the efficacy of this treatment. 3 4 We report a case of a man who developed avascular necrosis of both hip joints after depot corticosteroids were used to treat his …

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