Information
- Mechanism of action: corticosteroids exert a pluripotent anti-inflammatory effect via the inhibition of inflammatory mediator gene transcription but significant toxicity with prolonged use.
- Indication: Anti-inflammatory, the goal of therapy is to suppress disease activity with the minimum effective dosage.
- Dosage: highly dependent on disease and clinical situation.
- Medications: Prednisone (PO), prednisolone (PO), hydrocortisone (PO, IM, IV), methylprednisolone (PO, IV, intra-articular), dexamethasone (PO, IM, IV), and triamcinolone (intra-articular). The following are relative anti-inflammatory potencies of common glucocorticoid preparations: cortisone, 0.8; hydrocortisone, 1; prednisone, 4; methylprednisolone, 5; dexamethasone, 25. Prednisone (PO) and methylprednisolone (IV) are generally the preferred drugs because of cost and half-life considerations.
- Side effects: Adverse effects are related to dosage and duration of administration. Usually seen with doses >10 mg/d of prednisone (or equivalent). It may affect the following systems:
- Endocrine: Hyperglycemia, weight gain, iatrogenic Cushing syndrome, osteoporosis. Adrenal suppression can be assumed in patients receiving more than 20 mg of prednisone (or equivalent) for more than 3 weeks. The risk can be minimized by using a single daily dose of a short-acting preparation like prednisone. Adrenal crisis can develop in the setting of severe stress like major surgery or infection and should be treated with “stress-dose” glucocorticoids. For osteoporosis prevention, supplemental calcium, 1–1.5 g/d PO, should be given along with vitamin D, 1000 units daily PO, as soon as steroid therapy is begun. Bisphosphonates are most often used for prophylactic prevention of bone loss. A weight-bearing exercise program and avoidance of alcohol and tobacco are recommended.
- Cardiovascular: dyslipidemia, hypertension.
- Ophthalmologic: cataracts, glaucoma.
- Immunologic: Glucocorticoid therapy reduces resistance to infections which is the major cause of morbidity and mortality in these patients. Minor infections may become systemic, quiescent infections may be activated, and organisms that usually are nonpathogenic may cause disease. Local and systemic signs of infection may be partially masked, although fever associated with infection generally is not suppressed. Consider Pneumocystis jirovecii prophylaxis in patients on prednisone ≥20 mg for more than 1 month.
- Dermatologic: Acne, purpura, and cutaneous atrophy.
- Psychiatric: Changes in mental status ranging from mild nervousness, euphoria, and insomnia to severe depression or psychosis may occur.
- Musculoskeletal: Glucocorticoid can induce myopathy. Generally, affects proximal musculature, muscles are not tender, and generally CK, aldolase, and electromyography are normal. Myopathy resolves slowly after discontinuation. Ischemic bone necrosis can also occur; most commonly affects femoral head, humeral head, and tibial plateau.