Pharm

Systemic Corticosteroid

search

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

  • Precautions
  1. Systemic Glucocorticoids have significant adverse effects (see below)
  2. Systemic Glucocorticoids have many established indications with significant efficacy
    1. Asthma Exacerbation
    2. COPD Exacerbation
    3. Stress Dose Steroids
    4. Cancer Chemotherapy
    5. Peritonsillar Abscess
    6. Bells Palsy
    7. Acute Gout (in those unable to take NSAIDs)
    8. Extensive Allergic Contact Dermatitis (>20% of body surface area such as Rhus Dermatitis)
  3. However, many systemic steroid uses are NOT recommended (esp. for Upper Respiratory Infection) due to evidence against
    1. Not recommended in Acute Bronchitis (aside from acute COPD or Asthma Exacerbation)
      1. Hay (2017) JAMA 318(8): 721-30 [PubMed]
    2. Not recommended in mild to moderate Acute Pharyngitis (aside from Peritonsillar Abscess)
      1. Hayward (2017) JAMA 317(15): 1535-43 [PubMed]
    3. Not recommended in Acute Sinusitis
      1. Head (2016) Cochrane Database Syst Rev (4): CD011992 [PubMed]
    4. Not recommended in Allergic Rhinitis (use Inhaled Corticosteroids instead)
      1. Karaki (2013) Auris Nasus Larynx 40(3): 277-81 [PubMed]
    5. Not recommended in Carpal Tunnel Syndrome (use Carpal Tunnel Corticosteroid Injection instead)
      1. Wong (2001) Neurology 56(11): 1565-7 [PubMed]
    6. Controversial in Lumbar Radiculopathy (mixed study results)
      1. Goldeberg (2015) JAMA 313(19): 1915-23 [PubMed]
  • 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. See Stress Dose Steroid
    2. Parenteral: 100 to 150 mg IV/IM q2-6 hours prn
    3. 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 Precautions above
  2. See Prevention below
  3. Even short course Corticosteroids are associated with increased serious adverse effects
    1. Fracture (RR 1.9, NNH 140)
    2. Venous Thromboembolism (RR 3.3, NNH 454)
    3. Sepsis (RR 5.3, NNH 1250)
    4. Waljee (2017) BMJ 12:357 +PMID: 28404617 [PubMed]
  4. Corticosteroid Associated Osteoporosis
  5. Corticosteroid Myopathy
  6. Motor restlessness
  7. Sleep disturbance
  8. Hypertension
  9. Iatrogenic Diabetes Mellitus (or acute worsening of Diabetes Mellitus control including Diabetic Ketoacidosis)
    1. See Steroid-Induced Hyperglycemia
  10. Hyperlipidemia
  11. Fluid retention
  12. Immune Suppression
  13. Avascular Necrosis (e.g. Osteonecrosis of the hip)
    1. May occur even after single, short-term low dose course
    2. Dilisio (2014) Orthopedics 37(7):e631-6 +PMID: 24992058 [PubMed]
  14. 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)
  15. Cardiovascular disease risk
    1. Wei (2004) Ann Intern Med 141(10):764-70 +PMID:15545676 [PubMed]
  16. 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. See Steroid-Induced Hyperglycemia
  3. Avoid use when not truly indicated (e.g. Sinusitis, Acute Bronchitis, Pharyngitis)
    1. See Precautions above
    2. Even short course Corticosteroids (1 week) are associated with increased risk of Fractures, VTE and Sepsis
    3. (2017) Presc Lett 24(7)
    4. Waljee (2017) BMJ 357:j1415 +PMID:28404617 [PubMed]