FRAW LEY—COMPLICATIONS

OF

ACTH

AND

CORTISONE

THERAPY

593

Thyroid Depression: ACTH and cortisone may produce suppression of the
thyroid i as part of the over-all suppression of the anterior lobe of the pituitary
gland—thyroid-stimulating hormone being reduced as well as the production of
adrenocorticotropic hormone and gonadotropic hormone.
The reduction of
thyroid activity never reaches serious proportions and may be treated with very
small doses of thyroid. Caution should be exercised in using thyroid immediately
after the withdrawal of ACTH or cortisone inasmuch as thyroid administration in
the presence of adrenal cortical insufficiency, whether relative or absolute, may
prove fatal
Gonadal Depression: Serious complications arising from disturbances of the
gonads are unknown. However, there are certain changes which should be dis­
cussed. Probably the most common change noted is amenorrhea. This is usually
only temporary, lasting throughout the course of treatment, whereas normal menses
return two or three months after treatment has been discontinued. In the male
there may be a decrease in sexual drive, which occurs only if the treatment is pro­
longed and may not be due to gonadal suppression. No specific treatment is
indicated.
Other Changes.—In this category are included a variety of changes whose
physiological basis is not clearly defined as yet, but which appear with ACTH and
cortisone administration. One of the most important changes produced is an alter­
ation in the psychic state. Most commonly this is in the form of euphoria. It
develops to some extent in the majority of patients and is a part of the happiness and
delight over the disappearance of their disease. It is usually of short duration,
but in an occasional patient, it may become very disturbing. The change in mental
state does not always follow this euphoric pattern. In some patients mental depres­
sion may appear. This often takes the form of paranoid delusions. Usually the
euphoria or the depression will vanish on withholding treatment. In some patients
actual psychoses develop, and in addition to withholding therapy other measures,
such as shock treatment, may be necessary.
The serious complication of psychosis may be prevented by observing certain
precautions during treatment. The earliest precaution to be taken, is the proper
evaluation of the patient who is to be treated with ACTH or cortisone. In the
presence of a basic psychoneurotic pattern or emotional instability it is probably
wise whenever possible to withhold ACTH or cortisone treatment. In those
instances, however, in which it is necessary to use these agents, the earliest evidence
of abnormal behavior should be regarded as a warning signal and treatment should
be stopped. Often the patient describes a state of being bothered by several inde­
pendent unrelated trains of thought, none.of which he can concentrate on or carry
to completion. It is often so disturbing that the patient becomes anxious and has
insomnia. This may go on to the development of hallucinations, usually visual,
occasionally aural, and severe mental depression. In some instances it has been
possible to associate mental changes with marked electrolyte alterations due to
excessive sodium retention and cerebral edema or hypopotassemia. It is wise
to be on the alert for the possibility of these biochemical changes before concluding
that the cause of the mental disturbance is due to the hormones per se. In some
4. Hill, S. R., Jr.; Reiss, R. S.; Forsham, P. H., and Thorn, G. W.: The Effect of Adrenocorticotropin and Cortisone on Thyroid Function: Thyroid-Adrenocortical Interrelationships,
J. Clin. Endocrinol. 10:1375-1400, 1950.