Corticosteroid Dose EquivalentsChandler Medical Center, Compariwon, Kentucky. Systemic corticosteroids have been used in the treatment of numerous medical conditions for approximately 50 years. Short-acting products such comparisoh hydrocortisone are the least potent. Prednisone and methylprednisolone, which are intermediate-acting products, are four to five times more potent than hydrocortisone. Dexamethasone is a long-acting, systemic corticosteroid; its potency is about 25 times greater than the short-acting products. Anabolic steroids chemical name systemic corticosteroids potency comparison the need for hospitalization in patients with croup and decrease morbidity and the systemic corticosteroids potency comparison of respiratory failure in the treatment of patients with AIDS who have Pneumocystis carinii pneumonia.
A Different Look at Corticosteroids - American Family Physician
Chandler Medical Center, Lexington, Kentucky. Systemic corticosteroids have been used in the treatment of numerous medical conditions for approximately 50 years. Short-acting products such as hydrocortisone are the least potent. Prednisone and methylprednisolone, which are intermediate-acting products, are four to five times more potent than hydrocortisone.
Dexamethasone is a long-acting, systemic corticosteroid; its potency is about 25 times greater than the short-acting products. Corticosteroids reduce the need for hospitalization in patients with croup and decrease morbidity and the incidence of respiratory failure in the treatment of patients with AIDS who have Pneumocystis carinii pneumonia.
Other often overlooked indications for corticosteroids are the treatment of hyperthyroid states, including thyroid storm, subacute thyroiditis and ophthalmopathy of Graves' disease. Systemic steroids can be used as adjuvant analgesics in the treatment of neuropathic and cancer-related pain. They may also decrease mortality in patients with severe alcoholic hepatitis and concomitant encephalopathy.
Corticosteroids can reduce complications in patients with meningitis caused by Haemophilus influenzae or Mycobacterium tuberculosis. Corticosteroids were first used in clinical practice in for the treatment of rheumatoid arthritis. Indications since then have spanned multiple specialties and organ systems, including dermatology, rheumatology, immunology and oncology. This review covers practical uses of steroids as well as current and frequently overlooked clinical applications that may be helpful to family physicians.
If physicians understand the composition and physiologic effects of corticosteroid agents, appropriate drug selection can be made and inappropriate or problematic uses can be avoided. Corticosteroid agents mimic the endogenous steroid hormones produced in the adrenal cortex—mineralocorticoid aldosterone and glucocorticoid cortisol. Mineralocorticoids are primarily regulated by the renin-angiotensin system and possess salt-retaining properties.
Glucocorticoids are primarily regulated by corticotropin ACTH and can have anti-inflammatory effects, as well as several metabolic and immunogenic effects, on the body. While several corticosteroid agents possess properties of both hormones, fludrocortisone is most commonly used for its mineralocorticoid activity and hydrocortisone, cortisone, prednisone and prednisolone are used for their glucocorticoid effects.
Table 1 summarizes the relative potencies of the hormonal effects in addition to providing equivalent doses. Information from Drug facts and comparisons. Facts and Comparisons, Therapeutic effects of steroids can often parallel undesirable side effects, especially when high doses and long-term therapy are required. By anticipating the potential side effects and implementing preventive measures where possible Table 2 , 1 — 4 patients can obtain maximum benefits with minimum adverse effects.
Use with caution in patients at increased risk of developing osteoporosis; calcium supplements may be necessary, especially in postmenopausal women. The risk of these effects increases with increased dosages and prolonged use; use of antiulcer agents is suggested only in patients requiring long-term steroid therapy at high dosages; use with caution or avoid in patients with GI diseases in which perforation or hemorrhage are potential risks.
Precipitation of diabetes mellitus. In patients with diabetes, increased dosages of insulin or oral hypoglycemic agent and changes in diet should be expected. Use with extreme caution in patients with recent myocardial infarction because of an apparent association with left ventricular free-wall rupture.
Use with caution in patients with thromboembolic disorders because of reports of rare increased blood coagulability. Prolonged use may result in increased intraocular pressure or damaged ocular nerve.
Use in patients with ocular herpes simplex may cause corneal perforation. Muscle pain or weakness, muscle wasting, pathologic long bone or vertebral compression fractures, atrophy of protein matrix of bone, aseptic necrosis of femoral or humeral heads. Use with caution in patients prone to development of osteoporosis; risk versus benefit should be reassessed if osteoporosis develops; elderly, debilitated or poorly nourished patients may be more prone to these effects.
Supplementation with calcium, 1, mg per day, and vitamin D, IU per day, is recommended. Headache, vertigo, seizures, increased motor activity, insomnia, mood changes, psychosis.
Use with caution in patients with convulsive or psychiatric disorders. Use may aggravate preexisting psychiatric conditions. Steroid-induced psychosis is dose-related, occurs within 15 to 30 days of therapy and is treatable if steroid therapy must be continued. Pseudotumor cerebri reported during withdrawal.
Ecchymoses due to easy bruisability should be restricted to exposed, potentially traumatized extremities, when associated with steroid use. Contraindicated in patients with systemic fungal infections except to control drug reactions associated with amphotericin B [Fungizone] therapy. Do not use live virus vaccinations during therapy. Reactions to skin tests may be suppressed. Information from references 1 through 4. The dosage range for steroids is wide, and patient response is variable.
A low or maintenance dosage is approximately 0. Short-term, low-dose steroid therapy rarely results in any of the adverse effects listed in Table 2. In long-term therapy, alternate-day administration should be considered. Some disease states, however, such as temporal arteritis and systemic lupus erythematosus, may not be adequately controlled with alternate-day therapy. Doubling the dosage and administering the drug every other day in the morning more closely mimics the endogenous corticosteroid circadian rhythm.
This form of administration enables the patient to experience the therapeutic effects while side effects are minimized. To allow recovery of normal pituitary-adrenal responsiveness to secretion of endogenous corticosteroid without exacerbating the underlying disease state. In most patients, endogenous corticosteroid secretions are equivalent to 5 to 7. Tapering the dosage over 2 months or more may be necessary for patients on prolonged treatment more than 1 year.
Depending on dosage, duration of therapy and risk of systemic disease, decrease dosage by the equivalent of 2. Then perform a challenge to determine the extent of HPA axis recovery. Depending on the results and patient's symptoms, therapy may be discontinued or a slower taper considered.
Headache, dizziness, fainting, fatigue, lethargy, myalgia, joint pain, dyspnea, orthostatic hypotension, nausea, vomiting, anorexia, weight loss, fever, hypoglycemia, desquamation of skin.
If symptoms do not subside when steroid dosage is adjusted, other causes must be considered. Information from references 1 through 3 , and 5. Viral croup is a common childhood disease.
In fact, it is the most common form of upper airway obstruction in children six months to six years of age. Corticosteroids have been studied in the management of croup for the past 30 years, but their use in this condition is controversial.
The use of steroids in children with croup is associated with significant clinical improvement at about 12 hours post-treatment and results in less endotracheal intubation. Most current research focuses on outpatient use of corticosteroids in the treatment of moderate and severe croup. Some authors have found that routine use of steroids reduces the need for hospitalization.
Although budenoside is well tolerated with minimal side effects because of limited systemic availability, it is not yet available for use in the United States except in a nasal form. A single intramuscular injection of 0. Therefore, intramuscular corticosteroid treatment should be considered in patients with moderate croup before discharge from the emergency department when outpatient therapy is entertained.
Pneumocystis carinii pneumonia PCP is a leading cause of morbidity and mortality in patients infected with human immunodeficiency virus HIV.
This clinically significant complication of HIV infection occurs in 60 to 80 percent of patients with acquired immunodeficiency syndrome not receiving prophylaxis 14 and causes death in approximately 25 percent of its victims. Since the late s, adjunctive treatment with corticosteroids has been documented in case reports and research studies with favorable clinical results, and it is currently endorsed by the National Institutes of Health as a standard therapy.
Documented benefits of corticosteroid therapy in patients with PCP include reduced morbidity and mortality, decreased need for mechanical ventilation assistance and a reduced long-term decline in pulmonary function or exercise tolerance.
Progression of other opportunistic infections associated with HIV infection as a result of the immunosuppressive effects of corticosteroids is a risk that must be considered.
While some studies report only minor complications associated with steroid therapy, such as reactivation of localized herpetic lesions, 18 others have reported an increased incidence of infection and cancer.
Based on the benefits and risks of adjunctive corticosteroid therapy, the current recommendations are not intended for all patients but only for those with confirmed or suspected HIV and PCP infection who are at high risk of respiratory failure and death. Patients at risk include those with an arterial oxygen pressure of less than 70 mm Hg or an arterial-alveolar gradient of more than 35 mm Hg. The recommended dosing regimen is oral prednisone, 40 mg twice daily for five days, then 40 mg once daily for five days, then 20 mg daily for the duration of the anti-pneumocystis therapy.
Methylprednisolone, given at 75 percent of the oral prednisone dosage, can be substituted if parenteral therapy is necessary. A confirmatory diagnosis of PCP and HIV infection should be obtained, and other diseases, such as tuberculosis and cryptococcosis, should be ruled out before steroid therapy is begun. Further investigation is required to determine the appropriate use and benefits of steroid therapy when the patient has concomitant life-threatening infections and when the patient has already received more than three days of anti-pneumocystis therapy and has developed significant hypoxia.
Hyperthyroidism is a common disease affecting around 2 percent of women and 0. The amount of benefit and the effect on patient outcome in this circumstance is not yet known. Graves' eye disease is treated by first normalizing the thyroid function and then administering diuretics and systemic glucocorticoids.
Other causes of hyperthyroidism that may be treated with corticosteroids are subacute thyroiditis and thyroid storm.
Hyperthyroid disease related to thyroiditis is usually mild and self-limited. Beta blockers may be used to treat symptoms. In subacute thyroiditis, non-steroidal anti-inflammatory drugs or corticosteroids can be used to relieve thyroid pain and tenderness. Thyroid storm is a life-threatening condition of the hyperthyroid state.
Corticosteroids are used as adjuvant analgesics for pain in cancer patients and patients with neuropathic pain such as herpes zoster—related neuropathy, spinal cord compression and pain following oral surgery.
Prednisone, at a dosage of 7. Patients with nerve compression pain or pain resulting from increased intracranial pressure showed a better response when compared with patients with other pain syndromes. Perioperative use of corticosteroids has been advocated to reduce pain and decrease edema and trismus following oral surgical procedures.
The most significant improvement occurs in the treatment of postoperative edema. Dosages of prednisone between 40 and 80 mg per day can be used. Maximal benefit has been achieved after third-molar extraction, although some benefit has been reported after other surgeries. Some evidence indicates that combining corticosteroids with acyclovir Zovirax will decrease the duration of zoster-associated pain.
Systemic treatment with corticosteroids such as prednisone, at 40 mg per day for three weeks, decreases the proportion of patients affected by postherpetic neuralgia, especially pain occurring six to 12 weeks after onset.
Alcoholic hepatitis is a chronic, progressive and often fatal disease.