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Systemic Corticosteroid

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Systemic Corticosteroid, Corticosteroid, Betamethasone, Dexamethasone, Cortisone, Hydrocortisone, Methylprednisolone, Prednisolone, Prednisone

  • See Also
  1. Topical Corticosteroid
  2. Inhaled Corticosteroid
  3. Intranasal Steroid
  4. Intra-articular Corticosteroid
  5. Corticosteroid Associated Osteoporosis
  • Dosing
  • Adult
  1. Betamethasone (Celestone) 0.5 to 0.9 mg IM/PO qd
  2. Cortisone (Cortone) 25-300 mg PO qd
  3. Dexamethasone (Decadron)
    1. Antiinflammatory: 0.5-9 mg/day PO/IM/IV divided every 6-12 hours
  4. Hydrocortisone (Cortef)
    1. Parenteral: 100 to 150 mg IV/IM q2-6 hours prn
    2. Oral: 20 to 240 mg/day PO in divided dosing
  5. Methylprednisolone
    1. Parenteral (Solu-Medrol) 10 to 125 mg IV/IM
    2. Oral (Medrol) 4 to 48 mg PO qd
    3. Medrol Dose pack: tapers from 24 to 0 PO over 7 days
      1. Avoid medrol dose pack (replace with Prednisone 30 mg orally daily for 5 days would have similar effect)
  6. Triamcinolone (Aristocort, Kenalog) 4 to 48 mg PO/IM qd
  7. Prednisolone (Prelone) 5-60 mg PO/IV/IM orally daily
    1. Requires no first pass metabolism via the liver (unlike Prednisone)
  8. Prednisone (Deltasone) 5-60 mg orally daily
    1. Requires first pass metabolism through the liver, but has 1:1 bioavailablity in most cases
    2. Consider Prednisolone in severe liver disease
  9. Rayos (delayed release version of Prednisone)
    1. Marketed to reduce morning inflammation in Rheumatoid Arthritis
    2. Taken at 10 pm with intended release starting at 2 am
    3. Unlikely to add significant benefit for the cost (more than $200 for thirty 5 mg tabs)
    4. (2012) Prescr Lett 19(12): 69
  • Dosing
  • Child
  1. Methylprednisolone (Solu-Medrol)
    1. Dose: 1-2 mg/kg/dose PO/IV/IM q6h up to 125 mg/dose
  2. Prednisolone (Prelone)
    1. Dose: 1-2 mg/kg/dose PO qd to bid up to 60 mg/day
    2. Maximum: 60 mg per day
    3. Preparations
      1. Syrup: 15 mg/5 ml
      2. Liquid: 5 mg/5 ml
  3. Dexamethasone
    1. Asthma Exacerbation: 0.3 to 0.6 mg/kg/day up to 10-15 mg for 1-2 days
    2. Croup: 0.15 to 0.6 mg/kg once up to 10 mg
      1. See Dexamethasone in Croup
  • Agents
  • Overall potency (equivalent dosages)
  1. High potency
    1. Betamethasone 0.6 to 0.75 mg
    2. Dexamethasone 0.75 mg
  2. Medium potency
    1. Methylprednisolone 4 mg
    2. Triamcinolone 4 mg
    3. Prednisolone 5 mg
    4. Prednisone 5 mg
  3. Low potency
    1. Hydrocortisone 20 mg
    2. Cortisone 25 mg
  • Agents
  • Relative anti-inflammatory potency
  1. High anti-inflammatory potency
    1. Betamethasone 20-30
    2. Dexamethasone 20-30
  2. Medium anti-inflammatory potency
    1. Methylprednisolone 5
    2. Triamcinolone 5
    3. Prednisolone 4
    4. Prednisone 4
  3. Low anti-inflammatory potency
    1. Hydrocortisone 1
    2. Cortisone 0.8
  • Agents
  • Relative Mineralocorticoid Potency
  1. Mineralocorticoid Activity
    1. Cortisone 2
    2. Hydrocortisone 2
    3. Prednisolone 1
    4. Prednisone 1
  2. No Mineralocorticoid Activity
    1. Betamethasone
    2. Dexamethasone
    3. Methylprednisolone
    4. Triamcinolone
  • Agents
  • Half Life
  1. Long half-life (36-54 hours)
    1. Betamethasone
    2. Dexamethasone (~56 hours)
  2. Medium half-life (18-36 hours)
    1. Methylprednisolone
    2. Prednisolone (~36 hours)
    3. Prednisone (~36 hours)
    4. Triamcinolone
  3. Short half-life (8-12 hours)
    1. Cortisone
    2. Hydrocortisone
  • Adverse Effects (typically with Long-term Corticosteroid use)
  1. See Prevention below
  2. Corticosteroid Associated Osteoporosis
  3. Corticosteroid Myopathy
  4. Motor restlessness
  5. Hypertension
  6. Iatrogenic Diabetes Mellitus
  7. Hyperlipidemia
  8. Fluid retention
  9. Osteonecrosis of the hip
  10. Corticosteroid Induced Adrenal Insufficiency
    1. Typically does not occur if Prednisone 20 mg equivalent used <2-3 weeks
    2. Tapering is generally not required for shorter steroid courses (and raises total steroid dose)
  11. Cardiovascular disease risk
    1. Wei (2004) Ann Intern Med 141(10):764-70 +PMID:15545676 [PubMed]
  12. Psychiatric effects
    1. Includes depression, anxiety, mania, Psychosis, Delirium and Insomnia
    2. Typically occurs in first week of therapy and resolves within a week of stopping the Corticosteroid
    3. Most have mild to moderate symptoms but may be severe in up to 5% of cases
    4. Symptoms may also occur (uncommonly) with high potency Topical Corticosteroids, Intranasal Corticosteroids
    5. Incidence of psychiatric effects increases with dose
      1. Occurs in 1% of patients on Prednisone 40 mg orally daily or less
      2. Occurs in 5% of patients on Prednisone 40 mg to 80 mg orally daily or less
      3. Occurs in 18% of patients on Prednisone 80 mg orally daily or more
    6. References
      1. (2014) Presc Lett 21(12):69-70
  • Prevention
  • Corticosteroid complications
  1. See Corticosteroid Associated Osteoporosis
  2. Avoid use when not truly indicated (e.g. Sinusitis, Acute Bronchitis, Pharyngitis)
    1. Even short course Corticosteroids (1 week) are associated with increased risk of Fractures, VTE and Sepsis
    2. (2017) Presc Lett 24(7)
    3. Waljee (2017) BMJ 357:j1415 +PMID:28404617 [PubMed]
  • References
  1. Swadron and Hope in Herbert (2018) EM:Rap 18(9):16-8
  2. Lane (1998) Endocrinol Metab Clin North Am 27:465-83 [PubMed]