Adrenal suppression corticosteroid side-effects

Side effects of inhaled corticosteroids are relatively mild and include hoarseness, sore throat, oral candidiasis, and skin bruising. Severe side effects such as adrenal suppression, osteoporosis, and cataract formation are reported less frequently than with systemic corticosteroids, but clinicians should monitor patients receiving high-dose chronic inhaled therapy. 

Long-term use of oral corticosteroids may result in side-effects, such as peptic ulceration, adrenal suppression and subcapsular cataracts. 

Increasing the concentration increases the penetration, but not to the same degree. Solubility of the corticosteroid in the vehicle is an other determinant of absorption and efficacy. So different formulations of the same corticosteroid can end up in a different efficacy classification. Efficacy can be further augmented by using the corticosteroid under occlusion. Occlusion with plastic enhances penetration and also absorption. However, with increased absorption also the risk of systemic side-effects increases. Systemic absorption will suppress the pituitary-adrenal axis and may cause Cushing s syndrome and a plethora of other adverse events (see Chapter 24, Section Il.b). Even small amounts absorbed may already cause growth retardation in children. 

Metyrapone is a competitive inhibitor of 11 beta hydroxylation in the adrenal cortex, and effectively inhibits cortisol production. It is used in low doses, titrated to achieve plasma cortisol levels as close as possible to normal day-time values. Occasionally it is used in higher doses combined with replacement corticosteroid treatment. Its main side effects relate to overdosage and resulting hypoadrenalism, but it can also cause hirsutism and hypertension, due to accumulation of precursor steroids. Ketoconazole is also sometimes used to suppress adrenal steroid production, but its potential for hepatotoxicity limits its... 

Topical preparations usually contain relatively insoluble steroids, such as clobetasol propionate, triamcinolone acetonide, or triamcinolone diacetate. Side effects of this mode of drug application are usually milder and more transient than those seen after systemically administered steroids. However, potent topical corticosteroids, such as clobetasol propionate (Temovate), can suppress adrenal function when used in large amounts for a long time, especially when the skin surface is denuded or when occlusive dressings are employed. Since the high potency topical preparations carry a higher risk of local side effects, their use should be held in reserve. 

Orally administered corticosteroids are effective in the treatment of chronic bronchial asthma. The inhalation route has been widely used in attempts to avoid systemic side-effects, such as adrenal suppression, but evidence suggests that inhaled steroids are absorbed systemically to a significant extent. The respiratory tract epithelium has permeability characteristics similar to those of the classical biological membrane, so lipid-soluble compounds are absorbed more rapidly than lipid-insoluble molecules. Cortisone, hydrocortisone and dexamethasone are absorbed rapidly by a nonsaturable diffusion process from the lung, the half-time of absorption being of the order of 1-1.7 min. Quaternary ammonium compounds, hippurates and mannitol have absorption half-times, in contrast, of between 45 and 70 min. 

Horses appear to be more sensitive to the adrenosuppressive effects of aerosolized corticosteroids than human patients. Documentation of systemic absorption (adrenal suppression) of inhaled beclometasone and fluticasone raises concerns that other systemic glucocorticoid effects may occur following aerosol administration of corticosteroids. The administration of adrenosuppressive doses (>1600 p,g/day) of beclometasone dipropionate to asthmatic human patients does not produce the other systemic side-effects of glucocorticoid administration, including a roimd face (Cushingoid facies), polyuria, polydipsia, hyperglycemia, obesity, altered carbohydrate metabolism, osteoporosis, abortion, posterior subcapsular cataract and aseptic necrosis of the... 

Long-term use of corticosteroids leads to serious side effects, including suppression of the pituitary-adrenal axis, immunosuppression, muscle wasting, osteoporosis and impaired wound healing (see page 119 and Table 7.1). 

The replacement of systemic corticosteroid therapy and its attendant side effects in asthmatic and allergy patients with locally acting corticosteroids by way of aerosol inhalation devices is a gratifying success story. Even though dexamethasone phosphate was initially used for brief periods, the development of systemic effects such as adrenal suppression offered no advantage over oral therapy. Beclomethasone diproprionate showed itself to be hundreds of times more potent, and it produced no systemic symptoms even even on prolonged use with 400 pg daily doses. Some systemic symptoms developed at three to four times higher doses. 

Corticosteroid medications, including cortisone, hydrocortisone and prednisone, have great potential in the treatment of a variety of conditions, from rashes to lupus to astiima, but also carry a risk of side effects. Corticosteroids mimic the effects of hormones the body produces naturally in the adrenal glands. When prescribed in doses that exceed the body s usual levels, corticosteroids suppress inflammation. This can reduce the signs and symptoms of inflammatory conditions, such as arthritis and asthma. Corticosteroids also suppress the immxme system, which can help control autoimmxme diseases. 

Corticosteroids - Corticosteroids have a number of side effects that can restrict their use in asthma. The most troublesome of these is the suppression of normal adrenal function and the development of Cushingoid symptoms. Recently beclomethasone-17,21-dipropionate has been used... 

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