Growing threat of self-medication: Chronic dexamethasone injections and exogenous cushing’s syndrome

Dear Editor,

We read with great interest the report by Yadav et al.[1] on severe adverse effects following over-the-counter (OTC) cough syrup ingestion. The case highlights significant health risks associated with unregulated medication use, particularly in low- and middle-income countries (LMICs), where self-medication is prevalent.[2,3] This issue extends beyond common cough syrups to more potent and dangerous drugs, such as glucocorticoids.

To illustrate, we describe a case of a 23-year-old man who presented with progressive weight gain, muscle weakness, and overall health deterioration, with weakness predominantly affecting the proximal muscles of his lower limbs. He had been self-administering daily intramuscular injections of dexamethasone 8 mg for over a year, initially prescribed by a local quack for a chronic skin allergy. He continued using the steroid independently without medical supervision or evaluation by a dermatologist. On examination, he exhibited classic features of Cushing’s syndrome: moon facies, central obesity, and proximal muscle weakness at the hips. Large, broad, violaceous striae were observed on the abdomen, flank, chest, and axilla [Figure 1]. Additional findings included multiple bruises and superficial fungal infections (tinea corporis) in the groin. Laboratory investigations revealed suppressed serum adrenocorticotropin hormone (ACTH) levels (2.2 pg/mL; reference: 5–60 pg/mL) and normal serum cortisol (414 nmol/L; reference: 171–536 nmol/L), indicating hypothalamic-pituitary-adrenal (HPA) axis suppression. Dexamethasone was discontinued, and the patient was transitioned to oral hydrocortisone with a carefully structured tapering plan to promote HPA axis recovery.

Figure 1.

Large wide reddish-purple striae present over axilla, lateral chest, abdomen, and flank (arrows) and central obesity

This case underscores the grave consequences of unsupervised glucocorticoid use, a problem exacerbated during the COVID-19 pandemic due to misinformation and the widespread availability of steroids.[2,3] Unlike OTC cough syrups, steroids have life-threatening systemic effects, including severe immunosuppression, metabolic complications, and the risk of adrenal crisis upon abrupt discontinuation.[4] Current guidelines stress the necessity of tapering steroids for patients on therapy longer than 3–4 weeks to minimize withdrawal symptoms and support HPA axis recovery.[4] Recommendations include gradually reducing doses, switching from long-acting steroids (e.g., dexamethasone) to shorter-acting options (e.g., hydrocortisone or prednisolone), and adjusting decrements based on the initial dosage.[4]

Both the case reported by Yadav et al. and our patient highlights the urgent need for comprehensive strategies to address self-medication in LMICs. Factors such as limited healthcare access, unregulated medication distribution, inequitable resource allocation, a shortage of healthcare professionals, and high medical costs drive individuals to self-medicate.[2,3,5] We advocate for stronger regulatory policies to control the sale of potent medications like steroids and for public health initiatives to educate communities on the dangers of unsupervised drug use. Additionally, healthcare providers must remain vigilant in recognizing and managing complications arising from such practices.

Declaration of patient consent

Written informed consent is present. The patient’s brother was explained about the confidentiality, and the case information will be used for education purposes only.

Authors’ contributions

AKP: conceived the idea, collected patient data, drafted and revised the manuscript Conceptualization (lead); Writing-original draft (lead), Writing-review and editing (supporting). VS: Writing-original draft (supporting); Data curation (supporting); Writing-original draft (supporting). The corresponding author is responsible for ensuring that the descriptions are accurate and agreed upon by all authors.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.