Saturday, 25 May 2013

Steroids or corticorsteroids use

Corticosteroids also known as steroids are used for the treatment of inflammatory, autoimmune, and endocrine disorders, and nausea and vomiting symptom control in cancer patients.

Which corticosteroid should be used for a given indication?

Hydrocortisone is chosen only when sodium and water retention are desired (for its mineralocorticoid action) Intermediate-acting agents (prednisone, prednisolone, methylprednisolone) given once daily may minimize Hypothalamic Pituitary Adrenal (HPA-axis) suppression. Dexamethasone is used for certain indications such as in brain tumours and nausea and vomiting. Oral liquid prednisolone formulations are often used in children. 

Does the corticosteroid require tapering?

If you are on prolonged high dose of corticosteroids, you should not stop taking it suddenly as it may lead to a condition called adrenal insufficiency or lead to a flare up of your disease. 

Your doctor should instead taper the dose ( reducing the dose gradually before taken off the drug) 

General management include:
(1) taper by 5% to 20% every 1 to 2 weeks, depending in underlying illness; 
(2) increase dose and slow taper if patient complains of flulike symptoms or disease flare;
(3) consider switching to a shorter-acting agent (prednisone), consolidating multiple daily doses to a single morning dose, and converting to alternate day dosing,
(4) consider use of ACTH test to confirm adrenal recovery,
(5) consider increased dose or supplemental hydrocortisone in times of stress

Common corticosteroid indications and preferred corticosteroid
Adrenal Insufficiency
Hydrocortisone and flurocortisone. Hydrocortisone provides both mineralocorticoid and glucocorticoid activity. Flurocortisone provides additional mineralocorticoid if needed
Prednisolone. Prednisolone provides more glucocorticoid and less mineralocorticoid activity than hydrocortisone
Brain tumours
Chronic obstructive pulmonary disease (COPD)
Prednisone or Predinisolone or methylprednisolone
Connective tissue and rheumatic disorders (e.g., lupus, rheumatoid arthritis)
Prednisolone, methylprednisolone or Prednisone
Nausea and vomiting (radiation, chemotherapy, postoperative, pregnancy)
Corticosteroid Tapering to Prevent Disease Flare and/or Adrenal Insufficiency
Consider Tapering If…
Patient frail or very ill (e.g., severe hematologic, inflammatory, or immune disease); Treating disease flare in patient taking systemic steroids prior to flare; Patient has cushingoid symptoms (e.g., moon face, buffalo hump)
Consider Not Tapering If…
Course lasts less than 2 to 3 weeks (and no reason for taper such as those described in column to left); Treating asthma or COPD flare for 1 to 2 weeks (patient not on systemic steroids prior to flare); Patient being treated for allergic reaction which has resolved

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