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Correspondence  |   May 1997
Adverse Reactions to Nonindicated Medications 
Author Notes
  • Division of Pain Management, Department of Anesthesia and Perioperative Medicine, Medical University of South Carolina, 171 Ashley Avenue, Charleston, South Carolina 29425–2207.
Article Information
Correspondence
Correspondence   |   May 1997
Adverse Reactions to Nonindicated Medications 
Anesthesiology 5 1997, Vol.86, 1212. doi:
Anesthesiology 5 1997, Vol.86, 1212. doi:
To the Editor:-We read with interest the informative and honest case reports by Fishman et al. [1 ] concerning corticosteroid-induced mania after single applications of 100 mg of triamcinolone at the celiac plexus. The authors correctly indicate that corticosteroids can be associated with mental status changes, including mania and psychosis, and cite multiple references documenting this effect. The two patients reported had a history of mania from previous corticosteroid use and had repeat manic episodes with the depot steroids injected by the authors.
What concerns us is the use of medications without real benefit for which patients have a documented history of adverse reactions. Data concerning the use of corticosteroids as an adjunct in celiac plexus blocks for chronic pancreatitis are meager at best. Of the two references cited by Fishman, [2 ] one is a single case report. The other article is a report of the use of depot steroids for chronic pancreatitic pain in 16 patients, of which only 4 reported pain relief. [3 ] The two patients reported by Fishman et al. had histories of adverse reactions to previously administered corticosteroids, including one after a single intraarticular injection.
Although, as the authors state, the prognosis of corticosteroid-induced neuropsychiatric complications is good, it is not something to be considered lightly. One of the patients signed out of the hospital against medical advice (AMA), and the other was found at some distance from her hospital room after the onset of the mania. Fortunately, these patients had no apparent significant residual morbidity. However, the outcome of some psychiatric patients discharged AMA is poorer than those discharged with medical advice. [4 ] Certainly, the two patients reported on by Fishman et al. demonstrated lack of self control and poor decision-making during the 6 or 7 days it took for the mania to resolve.
As pain management anesthesiologists ourselves, we, like the authors, frequently prescribe and inject medications for purposes that have not been proven to be completely safe and efficacious in prospective clinical trials. It is the nature of the subspecialty that we should weigh the risks and benefits of a possible treatment and proceed from there. However, we disagree with injecting drugs with questionable benefit for which patients already have a history of adverse reactions.
Timothy L. Sternberg, D.M.D., M.D.; Nancy E. Cross, C.R.N.A., M.D.
Division of Pain Management; Department of Anesthesia and Perioperative Medicine; Medical University of South Carolina
171 Ashley Avenue; Charleston, South Carolina 29425–2207
(Accepted for publication January 30, 1997.)
References 
References 
Fishman SM, Catarau EM, Sachs G, Stojanovic M, Borsook D: Corticosteroid-induced mania after a single regional application at the celiac plexus. Anesthesiology 1996; 85:1194-6.
Hanowell ST, Kennedy SF, MacNamara TE, Lees DE: Celiac plexus block: diagnostic and therapeutic applications in abdominal pain. South Med J 1980; 73:1330-2.
Busch EH, Atchison SR: Steroid celiac plexus block for chronic pancreatitis: results in 16 cases. J Clin Anesth 1989; 1:431-3.
Fabrick AL, Ruffin WC Jr, Denman SB: Characteristics of patients discharged against medical advice. Mental Hygiene 1968; 52(1):124-8.