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Correspondence  |   May 1997
Reply  : Adverse Reactions to Nonindicated Medications
Author Notes
  • MGH Pain Center, Department of Anesthesiology and Critical Care, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts 02114.
Article Information
Correspondence
Correspondence   |   May 1997
Reply  : Adverse Reactions to Nonindicated Medications
Anesthesiology 5 1997, Vol.86, 1212-1213. doi:
Anesthesiology 5 1997, Vol.86, 1212-1213. doi:
In Reply:-We appreciate the comments of Sternberg and Cross and agree that clinicians faced with failed therapies for chronic conditions often rely on interventions that make theoretical sense but which may not have proven efficacy. This is certainly the case with pain from chronic pancreatitis.
We recognize that proceeding with local anesthetic and corticosteroid celiac plexus blockade requires consideration of the potential risks and benefits. In patients with history of corticosteroid sensitivity, the decision to proceed involves consideration of the potential for pain relief and the risks from mania, if it were to develop, and the likelihood of its successful management. Our cases suggest that mania can be a serious complication of corticosteroid usage from any regional procedure. In some cases, potential mental status changes may limit therapy, although if managed closely, mania can be self-contained and transient, perhaps even prevented with pretreatment with mood-stabilizing agents.
Adverse reactions from corticosteroids, even in patients with history of adversity to these agents, is not assured. When they occur, they usually are transient and manageable with conventional therapy. Arguing the efficacy of corticosteroid injections at the celiac plexus was beyond the scope of our presentation. Our experience has been that a minority of patients have markedly beneficial responses with corticosteroid injections at the celiac plexus, and others have no benefit. Short of chronic opioid therapy, with its set of risks and benefits, this procedure may be the last resort for some patients with chronic pain from pancreatitis. For some, the risk of transient and manageable adverse effects in exchange for possible, albeit unproven, benefit from a procedure with otherwise modest risk, is an acceptable choice.
It is an unfortunate reality of contemporary medicine that we often do not have data to clearly justify many of the treatments that are routinely used. Although we strive to improve our supporting data, we often are faced with balancing the lack of scientific proof with experience, clinical judgment, and compassion.
Scott M. Fishman, M.D.; David Borsook, M.D., Ph.D.
MGH Pain Center; Department of Anesthesiology and Critical Care; Massachusetts General Hospital
Harvard Medical School; Boston, Massachusetts 02114
(Accepted for publication January 30, 1997.)