Corticosteroids , systemic-public

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THE INFORMATION IN THE OBPHARM^MIS INTENDED SOLELY FOR USE BY THE MEDICAL PROFESSION. IT IS NOT INTENDED FOR LAY PERSONS. DOSAGES ARE FOR ADULTS

Systemic corticosteroids are used to treat numerous conditions including endocrine and rheumatic disorders, collagen diseases, dermatological, allergic states, asthma, rhinitis, gastrointestinal, and respiratory diseases. Complications of glucocorticoid therapy include include osteoporosis, hyperglycemia, and hypertension.

Betamethasone (Celestone®)
Corticosteroid. Anti-inflammatory.

For the reduction of neonatal mortality, (respiratory distress syndrome) RDS, and (intraventricular hemorrhage) IVH in women at risk for preterm delivery [1]

12 mg IM every 24 h X 2 doses [1]
12 mg IM every 12 h X 2 doses may have a similar effect [2]

1. Effect of corticosteroids for fetal maturation on perinatal outcomes. NIH Consensus Development Panel on the Effect of Corticosteroids for Fetal Maturation on Perinatal Outcomes.JAMA.1995 1;273(5):413-8. PMID:7823388
2 Haas DM, The first 48 hours: Comparing 12-hour and 24-hour betamethasone dosing when preterm deliveries occur rapidly.J Matern Fetal Neonatal Med. 2006 Jun;19(6):365-9. PMID:16801314

Dexamethasone (Decadron ®)
Corticosteroid. Anti-inflammatory.

For the reduction of neonatal mortality, (respiratory distress syndrome) RDS, and (intraventricular hemorrhage) IVH in women at for preterm delivery [1]

6 mg IM every 12 h X 4 doses

For the treatment of immune thrombocytopenia (ITP) [2,3]

                      10 mg IV every 6 h for 4 days OR
                     40 mg orally daily for 4 consecutive days
                      If platelet count remains below 30 × 10^9/L or there are bleeding symptoms by day 10 an additional 4-day course of dexamethasone (40 mg daily) may be given.
                     Initial response expected in 2 to 14 days, peak response 4 to 28 days

(0.25, 0.5 , 0.75 , 1 , 1.5 , 2, 4, 6 mg tablets; 0.5 mg/5 mL oral elixir or solution; 4 mg/mL, 10mg/mL parenteral solution )

. 2. Wei Y, Ji XB, Wang YW, et al. High-dose dexamethasone vs prednisone for treatment of adult immune thrombocytopenia: a prospective multicenter randomized trial. Blood. 2016;127:296-302.PMID: 26480931
3. Neunert C, et al., The American Society of Hematology 2011 evidence-based practice guideline for immune thrombocytopenia. Blood. 2011 Apr 21;117(16):4190-207. Epub 2011 Feb 16. PMID:21325604

Methylprednisolone (Solu-Medrol®)
Systemic Corticosteoroid. Anti-inflammatory.

For the treatment of asthma exacerbation [1-3]

40 to 80 mg/day IV or IM in 1 to 2 divided doses until peak expiratory flow is 70% of predicted or personal best

For the treatment of refractory hyperemesis gravidarum) in addition to other antiemetic being used (off -label [4]

16 mg orally or IV every 8 hours for 3 days. If no response after 3 days then discontinue . If patient responds, taper dose over 2 weeks. If vomiting recurs stop taper at lowest effective dose and continue for no more than 6 weeks.

ACOG advises " Treatment of severe nausea and vomiting of pregnancy or hyperemesis gravidarum with methylprednisolone may be efficacious in refractory cases; however, the risk profile of methylprednisolone suggests it should be a last-resort treatment."[4]

(40 mg Act-O-Vial System (Single-Use Vial) )

1. Guidelines for the Diagnosis and Management of Asthma (EPR-3) 2007 Availabale at:
https://www.nhlbi.nih.gov/health-topics/guidelines-for-diagnosis-management-of-asthma
2. Alangari AA.Corticosteroids in the treatment of acute asthma. Ann Thorac Med. 2014 Oct;9(4):187-92. :25276236
3.Krishnan JA, et. al., An umbrella review: corticosteroid therapy for adults with acute asthma.Am J Med. 2009 Nov;122(11):977-91. doi: 10.1016/j.amjmed.2009.02.013. Review.PMID: 198543212
4. Nausea and vomiting of pregnancy. ACOG Practice Bulletin No. 189. American College of Obstetricians and Gynecologists. Obstet Gynecol 2018;131:e15–30 PMID: 29266076 .

Prednisone (Deltasone®):
Systemic Corticosteroid . Prednisone is metabolized in the liver to its active form, prednisolone. Incomplete conversion of prednisone to prednisolone may occur in liver disease.

For Bell's palsy (idiopathic facial paralysis) treatment within 72 hours of onset
[1,2]

1mg/kg

For the treatment of immune thrombocytopenia (ITP) [4,5]

                      1 mg/kg body weight per day orally for 28 days, then tapered off to maintenance dose of less than 15 mg daily or complete terminaton of medication
                      Initial response expected in 4 to 14 days, peak response 7 to 28 days.
                      If a more rapid response is required use IVIG instead; IVIG initial response expected in 1 to 3 days, peak response 2 to 7 days

(1 , 2.5 , 5, 10, 20 ,50 mg tablets , 5mg/ml, 5mg/5mL)

1. Gillman GS, et al., Bell's palsy in pregnancy: a study of recovery outcomes. Otolaryngol Head Neck Surg. 2002 Jan;126(1):26-30.PMID: 11821761
2. Salinas RA, et al. Corticosteroids for Bell's palsy (idiopathic facial paralysis).Cochrane Database Syst Rev. 2010 Mar 17;3:CD001942. 20238317
3. Ramsey MJ, et al. Corticosteroid treatment for idiopathic facial nerve paralysis: a meta-analysis. Laryngoscope. 2000 Mar;110(3 Pt 1):335-41.PMID: 10718415
4. Wei Y, Ji XB, Wang YW, et al. High-dose dexamethasone vs prednisone for treatment of adult immune thrombocytopenia: a prospective multicenter randomized trial. Blood. 2016;127:296-302.PMID: 26480931
5. Neunert C, et al., The American Society of Hematology 2011 evidence-based practice guideline for immune thrombocytopenia. Blood. 2011 Apr 21;117(16):4190-207. Epub 2011 Feb 16. PMID: 21325604

Prednisolone (Delta-Cortef®):
Systemic Corticosteroid . Biologically active form of prednisone.

For Bell's palsy (idiopathic facial paralysis) treatment within 72 hours of onset
[1-4]

25 mg orally twice daily X 10 days for adults
Manage abnormal tear flow and impaired eye closure, if present, with tear substitutes (Lacri-lube), lubricants, and eye protection.

Consult an otolaryngologist or neurologist for patients with unclear diagnosis, rash, persistent paralysis, prolonged weakness of the facial muscles, or recurrent weakness.

(5 mg tablets , 5mg/5 mL solution, 15mg/5mL solution)

1. Sullivan FM, A randomised controlled trial of the use of aciclovir and/or prednisolone for the early treatment of Bell's palsy: the BELLS study. Health Technol Assess. 2009 Oct;13(47):iii-iv, ix-xi 1-130. PMID:19833052
2. Oczkowski W.Early treatment with prednisolone, but not acyclovir, was effective in Bell's palsy. Evid Based Med. 2008 Apr;13(2):44. PMID:18375697
3. Engström M, et al. Prednisolone and valaciclovir in Bell's palsy: a randomised, double-blind, placebo-controlled, multicentre trial. Lancet Neurol. 2008 Nov;7(11):993-1000. PMID:18849193
4. Sullivan FM, et al. Early treatment with prednisolone or acyclovir in Bell's palsy.N Engl J Med. 2007 Oct 18;357(16):1598-607. PMID:17942873
5.Grogan PM, Gronseth GS. Practice parameter: Steroids, acyclovir, and surgery for Bell's palsy (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology 2001; 56:830-836.
6.Quant EC, et al. The benefits of steroids versus steroids plus antivirals for treatment of Bell's palsy: a meta-analysis. BMJ. 2009 Sep 7;339:b3354. doi: 10.1136/bmj.b3354. PMID:19736282
7. Salinas RA, et al. Corticosteroids for Bell's palsy (idiopathic facial paralysis).Cochrane Database Syst Rev. 2010 Mar 17;3:CD001942. 20238317

Perioperative Steroids

Treatment with more than 5 mg of prednisone (or its steroid equivalent) for more than 3 weeks may cause adrenal cortical atrophy as a result of chronic suppression of ACTH production. Complete recovery of the hypothalamic-pituitary-adrenal (HPA) axis may take up to 12 months after glucocorticoid treatment has been discontinued [1-6]. During this recovery time the ability to increase cortisol production is limited, and stressful situations that increase the demand for cortisol may trigger adrenal insufficiency. Supplementation of the glucocorticoid dosage during stressful situations (stress dose) such as surgery and critical illness has been advised to prevent vascular collapse due to secondary adrenal insufficiency. The stress doses recommended depend on the intensity and duration of the stress[4, 5]. However, there is some evidence to suggest that "stress dose" steroids may be unnecessary, and that continuing steroid-dependent patients on their preoperative dose throughout the perioperative period should suffice to prevent a hypotensive crisis [7-10].

Nonetheless, the above studies may not apply to the pregnant state. It has been recommended by one author that patients with known Addison disease during pregnancy receive 100 mg of hydrocortisone every 6 to 8 hours during labor, and this is continued post partum for 24 hours. After 24 hours the patient may return to her prepregnancy regimen [15]. For women without Addison disease delivery appears to result in a similar rise in cortisol levels amongst women whether delivered vaginally or by cesarean section. However, initial cortisol values may be higher in women undergoing induction of labor and elective cesarean [11,12]. The timing of these increases in cortisol should be considered if "stress dose" steroids are to be prescribed.

Recommended Perioperative Hydrocortisone Glucocorticoid for Patients on Long Term Steroid Treatment [4,5].

IN ADDITION TO to the patient's usual dose of steroid preoperatively give the following:

Medical or Surgical Stress	Stress Dose	Duration
Minor (Colonoscopy)	Hydrocortisone 25 mg /day	Single dose day of procedure
Moderate (Hysterectomy)	Hydrocortisone 50 to 75 mg /day	50 mg intraoperatively then then 20 mg every 8 hour first day return to preoperative dose day 2
Major (Cardiac surgery)	Hydrocortisone 100 - 150 mg/day	50 mg intraoperatively then 25 to 50 mg every 8 hours for 2-3 days then return to preoperative dose by day 3

Other steroids may be substituted for hydrocortisone using the steroid equivalent dose; For example 1 mg methylprednisolone may be substituted for each 5 mg hydrocortisone.

Approximate Equivalent Glucorticoid Doses [3,13,14]:

Steroid Half life Approximate equivalent dose

Cortisone 8-12 hr 25 mg

Hydrocortisone (cortisol) (Cortef, Solu-Cortef) 8-12 hr 20 mg

Prednisone 18-36 hr 5 mg

Prednisolone 18-36 hr 5 mg

Methylprednisolone (Solu-Medrol) 18-36 hr 4 mg

Triamcinolone 18 -36 hr 4 mg

Dexamethasone (Decadron) 36-54 hr 0.75 mg

Betamethasone (Celestone) 36-54 hr 0.75 mg

For women whose medication history is uncertain an ACTH (adrenocorticotropic hormone) stimulation test may be done. The test is performed by obtaining a baseline serum cortisol, and then giving ACTH 250 mcg IV. The serum cortisol is drawn at 30 minutes and 60 minutes after the ACTH dose. Peak cortisol values greater than 18 micrograms/100 mL at any point during the ACTH stimulation indicate adequate adrenal-pituitary-hypothalamic function in the nonpregnant patient. An increase in cortisol above 2 to 3 times the baseline also indicates adequate adrenal function.

REFERENCE(S)

1. Jabbour SA. Steroids and the surgical patient. Med Clin North Am. 2001 Sep;85(5):1311-7. PMID:11565501

2.Lamberts SW, Bruining HA, de Jong FH.Corticosteroid therapy in severe illness. N Engl J Med. 1997;337(18):1285-92. PMID:9345079

3. Brunt MJ and Melby JC Adrenal Gland Disorders In: Noble J, ed. Textbook of Primary Care Medicine.3rd ed St. Louis, Mo: Mosby, Inc; 2001: 397-402.

4. Jacobi j. Corticosteroid replacement in critically ill patients.Crit Care Clin2006;22(2):245-53, PMID:16677998

5. Salem M, Perioperative glucocorticoid coverage. A reassessment 42 years after emergence of a problem.Ann Surg. 1994;219(4):416-25. PMID:8161268

6. Axelrod L. Perioperative management of patients treated with glucocorticoids. Endocrinol Metabol Clin North Am. 2003;32:367-383. PMID:12800537

7.Brown CJ,Buie WD Perioperative stress dose steroids: do they make a difference? J Am Coll Surg. 2001;193(6):678-86. PMID:11768685

8. Glowniak JV and Loriaux DL. A double-blind study of perioperative steroid requirements in secondary adrenal insufficiency.Surgery. 1997;121:123-9. PMID:9037222

9. Friedman RJ, Schiff CF, Bromberg JS. Use of supplemental steroids in patients having orthopaedic operations.
J Bone Joint Surg Am. 1995 Dec;77(12):1801-6. PMID:8550646

10. Bromberg JS, et al. Stress steroids are not required for patients receiving a renal allograft and undergoing operation.
J Am Coll Surg. 1995;180:532-6. PMID:7749527

11.Nwosu UC, et al. Parturition-induced changes in maternal plasma cortisol levels.Obstet Gynecol. 1975;46(3):263-7. PMID:1161228

12.Knapstein P. Fetal and maternal plasma cortisol levels during labour and after delivery in the human.Z Klin Chem Klin Biochem. 1975;13(8):351-3. PMID:1216960

13. Meikle AW and Tyler FH. Potency and duration of action of glucocorticoids. Am J of Med 1977;63;200. PMID:888843

14. Webb R, Singer M. Oxford Handbook of Critical Care. Oxford ; New York : Oxford University Press, 2005

15. Vagnucci A, Lee P. Diseases of the Adrenal Cortex in Pregnancy. Norwalk, Conn: Appleton & Lange; 1989