FRAWLEY—COMPLICATIONS OF ACTH AND

CORTISONE

THERAPY

595

return of all symptoms and signs it is usually only temporary and lasts 48 to 96
hours, followed by a complete or partial remission. In some patients with psoriasis
or rheumatoid arthritis the disease becomes much worse after stopping treatment.
There is nc> way, as yet, of predicting in which patients the disease will do this.
By withdrawing ACTH and cortisone therapy slowly many of these exacerbations
can be prevented.
CONTRAINDICATIONS

Hypertension.—Because of the salt and water retention which accompany ACTH
and cortisone administration they should be used cautiously in the presence of severe
hypertension. There is also experimental evidence that the adrenal steroids, par­
ticularly desoxycorticosterone-like steroids, act directly on blood vessels, thereby
aggravating hypertension. The restriction of sodium intake will tend to minimize
elevation of blood pressure, and the judicious use of diuretics often aids in reducing
accentuation of preexisting hypertension.
Congestive Heart Failure.—In general, ACTH or cortisone should never be
used in the presence of congestive heart failure. The only exceptions are those in
which the modification of the disease includes improvement in cardiac function or
reduces the load placed on the heart. As an example, an occasional patient with
acute rheumatic fever and congestive heart failure will improve so dramatically dur­
ing treatment that the hormone treatment may be safely given without compromising
the cardiac status. This has also been observed in instances of heart disease sec­
ondary to chronic pulmonary disease in which the improvement in the latter has
been so marked that concomitantly cardiac symptoms appeared to be reduced.
Renal Insufficiency.—In a previous publication it was shown that most renal
diseases, with the exception of the nephrotic syndrome, do not respond therapeu­
tically to ACTH and cortisone treatment.10 . Indeed, certain manifestations of renal
insufficiency are actually made worse. The blood nonprotein nitrogen tends to rise;
albuminuria increases. Unless there are good indications for ACTH and cortisone
therapy, these hormones should not be used in the presence of kidney impairment.
Peptic Ulcer —There are instances of active bleeding from peptic ulcers follow­
ing administration of ACTH and cortisone. This has occurred in patients whose
ulcers had previously been pronounced healed or inactive. Reports of perforation
of a peptic ulcer following ACTH treatment and activation of quiescent ulcers are
available.9 In- the case of the activation of a quiescent ulcer this therapy may prove
disastrous Inasmuch as some of the signs and symptoms which normally accompany
perforation of a viscus may be masked by the hormone effects. That intestinal
ulceration is not made worse by ACTH or cortisone in all instances is clearly
shown in the response which certain patients with ulcerative colitis lc obtain with
ACTH or cortisone treatment.
Tuberculosis and Syphilis.—In "both man and animals there is evidence indicating
that tuberculosis may be aggravated during treatment with ACTH or cortisone..
Therefore, they should be used with great caution in patients who might have active
9. Habif, D.; Hare, C. C., and Glaser, G. H.: Perforated Duodenal Ulcer Associated with
Pituitary Adrenocorticotropic (ACTH) Therapy, J. A. M. A. 144:996 (Nov. 11) 1950. Smyth,
G. A.: Activation of Peptic Ulcer During Pituitary Adrenocorticotropic Hormone Therapy,
ibid. 145:474-477 (Feb. 17) 1951.